Deck 3 Flashcards

Question

Prerenal azotemia

Answer 1

History of decreased fluid intake or insensible losses, inc'd sun - exam findings c/w volume depletion Pt taking NSAIDs vulnurable FENA can be >1% slightly if takes diuretic FE urea < 35% = pre-renal (less affected by diuretics) Urinalysis concentrated, high specific gravity

Answer 2

hypersensitivity rxn to med leukocyte casts, EOS in U/A recent med new

Answer 3

physiolgic insult to kidney - hypoxia, toxin, prolongued kidney hypoperfusion - Rapid kidney failure Muddy brown casts

Answer 4

no dysmorphic RBC or erythrocyte casts

Answer 5

Pt with Hep B/cirrhosis HCC screening with US q6-12m Nodule in liver found on US (Screening) Contrast CT/ Gad MRI next - no need for bx - characteristic blood supply from hepatic artery (neovascularization) Don't just repeat in 6 months

Answer 6

diffuse cutaneous systemic sclerosis aw gastric antral venous ectasia (GAVE) - causes GIB - pt p/w fatigue, dypnea, IDA Tx: EGD - photo/laser coag No Epo unless causes of IDA excluded No need for BM bx Colonoscopy only if altered BM, or if EGD neg No hydrogen breath test - no sx of bacterial overgrowth (bloating, steatorhea, abd pain

Answer 7

develop in skin with decreased or absent sensation areas of trauma/friction (metatarsal heads) painless thick macerated rim hyperkeratosis Debridement - off loading of pressure, watch for OM

Answer 8

setting of severe PAD Painful, well demarkated ulcers any part of limb but usually over bony prominance Absent periph pulses, cool skin, pallor

Answer 9

small vessel vasculitis painful, irregular shaped, punched out erythema, purpura

Answer 10

varicose veins, medical legs around medial maleous, hyperpig and sclerotic (lipodermatosclerosis)

Answer 11

Pt has +PET shows likely areas of LN spread of CA but not confirmed - need mediastinal LN bx EBUS or medistinoscopy FOR STAGING CT guided bx of primary lesion not needed first - need Medistinal LN for staging Need to stage before surgery or chemo decided

Answer 12

``` Shiga toxin prodcuing E. Coli E O157:H7 produces shiga toxin - not preformed - gross blood in stool contaminated food - undercooked burger abd tenderness, leukocytosis ```

Answer 13

foodborn GI illness - PREFORMED TOXIN - sx < 24 hrs | n/v not gross blood/diarrhea

Answer 14

foodborne Gastroenteritis - no gross blood

Answer 15

``` PDE inhibitor (not a nitrate drug) if fewer than 3 CV risk factors CV risk factors: Age, HTN, DM, Smoking, HLD, sedentary lifestyle, fhx premature CAD ``` Testosterone replacement only if low Don't stop metoprolol in pt with metoprolol

Answer 16

Buttock and hip caludication, diminsihed femoral pulses and erectile dysfxn (Lerich syndrome) -> aortoilliac dz Common femoral - thigh pain with effort, NO ED Tx: surgery or POBA NOT stent Popliteal artery - pain in lower calf - tx with excercise program and med tx - if no benefit then bypass SFA - pain in upper calf - tx with med therapy first then angioplasty

Answer 17

elevated r/o SJS from carbamazine, phenytoin, oxacarbazzpine, lamotrigine but NOT levetiracem (keppra) findings of Todd paralysis Partial focal lesion-> generalized Asian patient need genetic testing

Answer 18

tPA guidelines w/in 3-4.5 hrs <220/120

Answer 19

``` Dynamic LVOT obstruction Systolic murmur inc'd with dec'd preload (valsava) Dec'd by increasing afterload (handgrip) Asymmetric septal hypertropy +- mid cavitary obstruction Small LV cavity, LAE, diastolic dysfxn Sx: Asx, dizziness, CP, dyspnea ```

Answer 20

Weight lifter LV cavity ENLARGED no LAE NO diastolic dysfxn

Answer 21

impaired diastolic filling (HTN CM)

Answer 22

accentuated early diastolic filling

Answer 23

``` dx: Radioactive Iodide uptake test destructive thyroiditis h/o viral infection fever, elev ESR High T3, T4, low TSH RAIU t work in destructive thyroitis Tx: BB tx ``` Serum thyroglobulin - differentiate between destructive thyroitidits vs exogenous levothryoxine use

Answer 24

acral lentigous melanoma originates under nail pigment extends to adjacent skin (hutchinson's sign) wider area of pigemnted area on prox end - indicates expanding of lesion

Answer 25

pigment lines lighter and constant diameter - multiple nails

Answer 26

2/2 trauma Dark brown or black violet/red hue

Answer 27

nail fungus - variety of colors - multiple nails - dx with nail clipping KOH

Answer 28

``` testicle twists on spermatic cord men < 30 severe sudden pain high riding testicle abscent cremater reflex (99% sensitive) Rapid surgical decompression ```

Answer 29

subacute onset scrotal pain, dyuria, freq/fever Posterior adn superior testicle Scrotom edematous/erythematous - not from malpositioned testicle

Answer 30

asx bulge, feeling groin/abd presure - painful mass in scrotum with signs of bowel obstruction

Answer 31

``` inflammation of testicle viral (mumps) ext of bacterial infxn from epididymitis or UTI Mump - parotidits 5 days prior Testicle DIFFUSELY tender/swollen postion testicle normal +cremaster reflex ```

Answer 32

Progressive CKD with metabolic acidosis bicarb < blank - > add oral sodium bicarb - slows CKD progression causes chronic bone dz - as bone buffers pH in met acidosis affects, Thyr, CAD, GH, muscle strength No need for allopurinol unless gout/gallstones No phophate binder if Phos norma No kayexalate if K normal

Answer 33

Best test is HRCT restrictive PFT, dec DLCO DDX: IPF, nonsp interstitial PNA, cryptogneic organizing PNA, hypersensitivity pneumonitis CT x 1 = solar radiation x 1 year MRI not preferred for lung PET not good enough VQ not correct test

Answer 34

except in pregnancy and prior to invasive uro procedure DO NOT TX asymptomatic bactiuria (do not tx non-preg F, ppl with chornic foley) Cipro and bactrim ok for UTI No US needed, no repeat u/a uctx

Answer 35

Non-seminoma - elevated AFP (always AFP with non-seminotoma - embryonic or yolk sac tumor) Seminoma - NO AFP - could have elev BHCG Epidiyditmis - tender testicular mass - fever, abn u/a, WBC Hematoma - testicular trauma - not with elev AFP/BHCG Testicular torsion - severe pain - n/v - ABSENCE of cremasteric reflex - high riding testicle no tender nodule, no high AFP

Answer 36

myalgia, abd pain, wt loss h/o IVDA active hep B - HB Sag, Hep B e Ag Elev ESR aneurysm of mesenteric and renal arteries Prednisone for polyarteritis nodosa TREAT HEP B - entecavir Polyarteritis nodosa - painful cut nodules, skin ulcers, palp purpura, livido retuclaris, More severe dz - steroids with cyclophosphamide Rituximab or TNF alpha - contraindicated with active hep B (exacerbates viral replication) Mycophenilate Mofetil - steroid sparing tx - prevent relapse in other forms of systemic vasculitides - after initial response to cyclophophamide - no role in primary/initial tx of Polyarteritis nodosa

Answer 37

Pt with weight gain, pleural effsuions, peripheral edema, relaively elevatd CVP -> should diuresis patient Early use of paralytics has been shown to improve moratlity and decrease duration of mecahnical ventillation - not widely adopted Prone positioning only in severe ARDS patients inhaled NO on ards patients improved oxygenation but not mortaily

Answer 38

Pt with modestly elevated prolactin FIRST - pregnancy test even if h/o prolactinoma Acromegaly - prognathism, enlargement nose, lips, tongue, frontal bossing, dental malocclusion, increased space between teeth, sleep apnea, enlargement hands/teeth, arthritsi, carpel tunnel, skin tags, oily skin, Prolactin co-produced 40% time - amenorrhea, galactorrhea Measure IGF-1 not GH No evidence of cushings - don't measure serum cortisol (muscle wk, echymosses, hypokalemia, osteoporosis, new onset HTN, DM, amenrrhea Vision test if temporal field vision loss

Answer 39

Stool osm gap =290-2(stool K + Stool Na+) If = >100 then osmotic diarrhea ie lactose malabsorbtion reduce lactose intake Stool gap < 100=secretory diarrhea ( Cholecytecomtom would not expalin stool osmol gap so not bile salt diarrhea Microscopic colits - secretory diarrhea eosinsophilic gastroenertis - either secortory or osmotic diarrhea very uncommon Osmotic gap not with irritable bowel syndorme

Answer 40

Methotrexate within 3 months of onset of any duration or degree +RF, +Anti CCP, elev ESR Distal PIP morning stiffness >1 hr Etanercept if high dz activity with poor prognostic factors Hydorxychloroquin with MILD cases only wihtout poor prognostic factors Do not wait and reeval unless +Parvo B19 or hep B (mimik early arthrtis)

Answer 41

``` Ostium secundum defect RV parasternal impulse/heave fixed split S2 RVH, RAH RAD inc RBBB systolic murmur inc'd flow thru pulm artery Diastolic murmur - inc'd flow thru tricuspid 2/2 L-> R shunt ```

Answer 42

severe pulm HTN 2/2 congential cardiac dz Cyanosis/clubbing Pulm HTN -> pressure RVH P2 inc'd - no fixed split S2 enlargement central pulm arteries - reduced peripheral pulm vasculature RAD, RVH with strain

Answer 43

Young men parasternal lift, inc'd pulm component S2 RAD, RVH with strain

Answer 44

``` prominent apical impulse loud S2 S2 inc'd with pulm HTN opening snap diastolic murmur LA enlargment post displacement heart ```

Answer 45

Surgical resection followed by chemo (stage II (I)) NSCLC - no nodes + No radiation Rad/chemo if non-resectable (Stage III) Chemo only (Stage IV metatastic) + selective rad (bronch compression, SVC syndrome, bony mets)

Answer 46

anteromedial aspect of proximal tibia distal to joint line of knee worsens with step climbing UP and at night Overuse (runners)

Answer 47

knife like LATERAL knee pain flex/ext activities of knee ie running consevative tx with rest/streching worse walking UP and DOWN steps

Answer 48

men peripatellar from running, descending stairs, prolonged sitting pain on compression of patella (+aprehensiveness)

Answer 49

Pain anterior knee | swelling/tenderness to palpation lower pole patella

Answer 50

salmonella enterica - typhi - ingestion in endemic area 1-4 week incubation Escalating fever 104deg bradycardia, sig abd pain, constipation/diarrhea salmon colored maculopapules on trunk distended tender abd with splenomegaly anemia, leukopenia, thrombocytopenia elevated bili and aminotransferases HYPONATREMIA isolation of salmonella typhi blood, stool, BM or skin Vaccines not ENTIRELY effective

Answer 51

Zoonotic infxn chronic fever, bone/joint sx, neuro/neuropsych sx weakness/malaise No rash

Answer 52

``` protozoal dz sandfly wt loss, fever, HSM pancytopenia, hypergammaglobinemia incubation - several months after exposure in endemic area ```

Answer 53

cyclic pattern of fever, no GI sx, NO RASH

Answer 54

Start Statin (pravastatin) - not zocor as had statin myopathy previously with zocor - check CK prior to starting (r/o progression to rhabdo, AKI, myoglobinuria) Low risk of ischemic stroke but high risk of operative procedure No carotid revasc for asx 80%, rapidly progressive stenosis, asx infarcts on imaging, Tx with OMT for PAD - has CV equivalent - LDL goal 80) and comorbidies bad candidate for revascularization

Answer 55

OTC decongestants contain pseduoephedrine or phenylephrine or NSAID - all raise BP in prev well controlled BP combination ACEi/ARB not good - decreases proteinuria BUT significant side effects and no clear benefit for CKD May increase ACEi or ARB but first need to make sure extra meds not increasing BP given BP was previously ok

Answer 56

``` Septic shock -> triggers ARDS (one reason)\ Acute hypoxemic respiratory failure Onset 48-72hrs after risk factor don't have to r/o CHF b/l alveolar opacities Chest CT Mild, mod or severe ``` Ecoli pneumonia not common Not CHF - normal CVP, no cardiomegaly

Answer 57

infiltration of lung parenchyma by eos fever, cough, dyspnea, b/l infiltrates EOS in bronch lavage unlikely with G neg sepsis

Answer 58

During excercise - hypoinsulemia state (no insulni before excercise) stiulated hepatic glucose release (If pt had DKA means completetly insulin deficient) without insulin - muscles can't uptake glucose - and further demand by excercise inc'd more hepatic gluconeogenesis Need adequate insulin BEFORE run Excess carbs would inc glucose but not specifically after excercise gastroparesis does not explain hypergylemia after run 12hrs after last eaten

Answer 59

IV Vit K and prothrombin complex concentrate (PCC) PCC can be reconstictuted in minutes (lyophilized) FFP would take several hours to prepare - too slow Oral vit K too slow

Answer 60

Need to keep BP t reduce CVA/CAD HLD associated risks Intracranial stenting not proven yet Warfarin only superior in pt with afib

Answer 61

Pt with CKD particulary vulnurable Avoidance of contrast best if needed - low osmolar contrast agents and hydration promotes urine and avoid volume contraction decrease risk Isotonic saline IV best (with bicarb no better) diuresis with mannitol or loop diuretic doesn't help Oral hydration not as effective PPX HD - NO BENFIT (even harm)

Answer 62

woody induration of extremities sparing hands and face in ABSENCE of raynauds Scleroderma spectrum d/o Bx: lymphocytes, plasma cells and EOS infiltration +- peripheral EOS

Answer 63

skin of upper torso and girdle - long standing IDDM

Answer 64

skin invovlement prox to distal forearms and knees subcut calcinosis Raynauds in 95%

Answer 65

Only in pt with MRI with Gad and ESRD on HD | Unlikely with no GAD and no ESRD

Answer 66

Inflammatory condition of pericardium and myocardium Etio - can be viral Pleuritic CP, regional/diffuse concave down ST elev, regional or global WMA with +CE -> NON OBSTRUCTIVE CORONARIES ON CATH

Answer 67

CP "Ripping" in quality Discrepancy in BP of arm, diastolic murmur of AI can occulde coronary with retrograde dissection of LCC or RCC

Answer 68

coronary vasosapm can also cause MI - however no vasosapsm on cath makes less likely Absense of coronary throbus/occlusion makes AMI unlikely

Answer 69

not aw EKG or WMA Not eccentuated by recumbanet positon (lying on back) better leaning forward PE won't cause WMA, or +CE

Answer 70

Women >40 Collagenous colitis - bx - subepithelial collagen band in lamina propria Lymphocytic colitis - bx - inc'd intraepithelial lymphocytes Colonscopy bowel looks normal in both chronic relapsing rmiting watery diarrhea aw wt loss, abd pain, fatigue, nausea comorbid dz - celiac, DM, thyroid dz, RA Etio - abn mucosal response to luminal exposures (infxn/drugs - lansaprozole, NSAIDS, sertraline, ranitidiine, ticlodipine, acarbose) Supportive Tx: loperamide 2nd line mesalamine, budesonide Refractory - prednisone If do not respond test for co-existing celiac dz - gluten free diet (check TTG)

Answer 71

Initial Tx: Jaw heat, relaxation, therapeutic excercise Clikcing on jaw movement - unilateral jaw discomfort esp on chewing Cog beh or biofeedback tx - reduce pain, depression, jaw applicance (no proof this works) Fluoxetine/NSAIDs no good evidence Only if jaw locking or structural jaw issue get jaw MRI Dx of TMJ clinical - radiography only good if suspect co exiting dental dz

Answer 72

Likely epidural abscess with acute presentation, mild fever, signs of OSTEOMYELITIS on MRI, DISKITIS, h/o IVDA EMERGENY SURGICAL DECOMPRESSION within 24-36hrs Afther ctx - empiric abx can be started Med tx only if localized pain/radicular sx Radiation Tx (emergent) not for epidural abcess - only if was malignancy

Answer 73

Delirium tremons fluctuating conciousness reduced attention, global amnesia, impaired cognition and speech, hallucinations/delusions 48-96 hrs after last drink - seizures can occur tx: benzodiazpines (lorazepam) CT of head if any neuro dificits Do not use HALDOL - lowers seizure threshold, masks sx of withdrawal Lactulose enema for hepatic encephalopathy - but doesn not cause agitiation, hallucinations, diaphoresis, tremulousness

Answer 74

If was on ASA - substitute plavix Don't use both unless CAD with PCI - risk of hemorrhage Dont use ticlodipine - s/e agranulocytosis and TTP Only use warfarin or NOAC if evidence of afib or LV thrombi

Answer 75

venous HTN, chronic inflamm, microangiopathy etio Location - medial maleous Skin is red, warm, eczematous, hyperpig, hemosiderin deposition, visible varicose veins, skin/SQ tissue thicken with stasis dermatitis -> lipoderatosclerosis Asteatoic eczema - winter itch, anterior shins of old people with dry skin - red dry cracked, small fissues more common in winter and dry conditions Cellulitis - usually UNILATERAL, +fever/WBC, pain, acute course DVT - pain/swelling in calf -

Answer 76

MRI/CT to assess recurrent coarct or aneursym - late complications after repair Bicuspid aortic valve common aw aortic coarct also have HTN Do not replace valve if asx - wait for higher gradient or symptoms or high risk features (will likely be required in future) No need for invasive cath (MRI/CT and Echo sufficient for anatomy and hemodynamics) No aortic stent if no signs of recurrence of coarct

Answer 77

NeuroSx proc/ issues, IC hemorrhorage - keep plt >100K (first few days) Nonneurosx proc, non-central nervous system bleeding - keep plts>50K

Answer 78

CT showing small bowel wall thickening with pneumatosis Metabolic acidosis elevated lactate Pain out of proprotion to exam Etio - likely ischemic embolus -> SMA (from LV/Atrial thrombus) or cardiogenic shock Dx: CT angio Crohns could cause small bowel thickening but not acute presenataion, shock, met acidosis INtesuccuptio - bowel obstruction Acute pancreatitsi - unlikley to lead to quick shock - CT woul have pancreatic edema

Answer 79

Protects against Strep Pneumococcus 23 antigens 60% Adults age 65 and older need one shot of pneumococcus Special populations: alaskan natives, American indians, long term care residents, radiation tx, immunsuppresives, smokers, chornic pulm d/o (including asthma), CVD, DM, CKD, cocklear implants, asplenia, immune d/o, malignancies High level ab x 5 years If vaccine 65 or older no booster immunocompetants vaccinated b4 65 get one AT 65 or 5 years after vaccine if vaccinated between 60 and 64 Immunocompromised or aplenia get booster 5 years after initial vaccine Never give MORE THAN 1 booster All pts with vaccine before 65 need booster after (5 years after or 65 whichever later (unless original vaccine 65 or older)

Answer 80

NOT candidate for ESTROGEN containing contraception (oral, vaginal, transdermal) - inc'd r/o thrombosis with antiphopholipid Ab aw 2nd /3rd trimester preg losses USE progesterone ONLY contraception ie prog intraunterine device or progesterone only pill (less effective, higher rate of breatkhru bleeding and other s/e) No combination contraception pills (contain estrogen) in pts with antiphospholipid Ab's, h/o thrombosis or other contraindications - ok for antiphopholipid ab neg SLE pts Don't use IM Medroxyprogesterone - ihibits ovulation and not recommended for long term use - aw risk of osteoporois (rel contraindication in pt with osteoporosis)

Answer 81

Celluits aw purulent drainage or exudate but without drainable abscess - Outpt Tx: bactrim (CA-MRSA), linezolid, tetracylcine (doxy), clindamycin Pop: chilren, MSM, student and pro athletes, prisoners Don't use amoxicililn, cephalexin, dicloxacin - active vs B hemolytic strep but NOT CA-MRSA (only for NON-purulent cellulits)

Answer 82

Obtain plasma aldo-renin ratio (ARR) Resistent HTN - BP above goal despite 3 anti-HTN including one diuretic (renovasc HTN, primary hyperaldo) Primary hyperaldo - not nec low K+ Also check for urine - aldo excretion (>12mg aldo in urine after 3 days of of high sodium diet and correction of hypo K+) - can use saline infusion Don't just sub loop for thiazide - ONLY FOR PTS with resistant HTN AND CKD or hypervolemic states DOn't just switch to other alt agent to lisinopril Pt has no risk factors for renovasc HTN, check ARR first (usually aw widespread atherosclerosis, vasc, CVD, ischemic end organ damage)

Answer 83

Neutrophilic dermatosis aw underlying malignancy (AML) Pt with MDS -> sweet syndrome inidcated -> AML "juicy" bright red demarcated plaques with sharp cut off between normal and inflammed skin - neck upper trunk extrem's Bx: neutrophillic inflamm infiltrate/papillary dermal edema bullae neutrophillic/fevers

Answer 84

immunocompromised host | cutaneous vesicles - rupture-> erosions

Answer 85

red to violacious dermal papules and nodules | bx: atypical leukemic cells infiltrating dermis and dissecting thru collagen bundles

Answer 86

large red, indurated tender warm papules - crusted papule/head at center of furuncle

Answer 87

small benign vascular papules with collarette of scale - occur anywhere, tend to be on extrem around nails and face - ppl on HAART and acne meds tend to get

Answer 88

infrequent convulsive seizures provoked by etoh or sleep deprivation absense seizures and myoclonic seizures worse in AM Fhx convulsive sz or myoclonic jerks

Answer 89

may have convusions - usually have remission by puberty

Answer 90

NO morning jerks or absnese seizures

Answer 91

with or without aura can be initial presentation of temporal lobe epilepsy No morning myoclonus

Answer 92

24 hr continuous ecg monitor - if daily sx PVCs - made worse with caffein, nicotine, etoh Usually benign unless fhx struc heart dz, sudden cardiac death, syncope Tx: reassurance EPS - for ppl who have sx such as syncope which could be VT (int or greater risk) can get mechanism and location of arrythmia Event recorders - sx that do NOT occur daily Implantable Looping recorder - records events prior to event device being triggered in response to arrythmia (very infrequent) Post sx recorder - good for arrthmias that pt can activate device (not if syncope)

Answer 93

inc'd H/H>18.5/16.5 (M/W), and O2 sat >92% JAK2 V617F analysis erythromelagia (burning sensation in palms and soles - from plt activation plethora warm water induced prurutiis thombotic and bleeding sx Leukocytosis / basophllia, thrombocytosis BCL-ABL - philadeophia chormoosome - CML leukoerythroblastics smear - inc'd granulocytes, left shift - , hypercell BM with myelooid prolif BMBx - pt with MDS but JAK2 neg hypercell marrow, abnormal megakaryocytes, in'c retuiculin fiborosis Sleep study in pt with Hg>18 and OSA-> secondary erythrocytosis

Answer 94

``` NO ABX chorpheniramine - antihistamines Sx relief is goal conjuntival injection, boggy nasal mucosa with clear drainage oropharynx edematous decongestant ``` Albuterol does not help ``` Caused by viruses - no abx Bacterial only if >10 days, with persisent sx (fever, h/a URI) onset with sev sx new fever, h/a, URI TX: augmentin (if bacterial) ``` NO role for codeine in tx Nasal ipratropium, cromyln, nasal decongestnats Vit c, echnasia, zinc,

Answer 95

Tacrolimus/cyclosporin/sirolimus cw macrolide abx (clarithro) and azole antifungals interfere iwth cytochrome 450, inc levels of anti=reg meds inc'd levels of tacrolimus inc'd Cr tubular d/o, HTN, neurotox, metabolic abn, hyperglyc, hyperK, hypoMg Use AZITHRO if macrolide needed Mycophenilate -> GI/ BM suppresion sx, BM suppresion NO AKI - macrolide abx do not affect this drug Acute interstitial nephritsi - hypersensit rxn to med fever, rash, eos U/A leukocyte casts, EOS, protein 2.5 Organ rejection - no likely at 7 months

Answer 96

High risk = III | peptic ulcers with pulsatile bleeding, non-bleedin vessel, adherent clot

Answer 97

Fhx of elevated Ca Check Urine calcium to Cr ratio Ratio < 0.1= suggest benign familial hyppcalciuria, hyperCa+ High serum Ca Genes - Measure prolactin level - MENI 25OH3D - high serum Ca high PTH -

Answer 98

OA like arthrtis atypical joints (MCP)+chondroCA (dep of Ca in soft tissue - see on xray) radiology - subhcondral sclerosis, osteophytes) Hemochromatosis/CPP arthropathy - overalp no evidence of Iron overloa on labs Peudogout - hass CPP crytals in joint (wk b Rheum arthrits - +RF, +anti ccp, morning stiffness>2hrs

Answer 99

BP controlled to SBP<150 - BV stiffer so erronious high BP and put on many meds that cause serious s/e in elderly No need to add diuretic or change meds

Answer 100

Use atorvastatin (or pravastatin) not as much interaction with PI (ritinovir) (cytochrome p450) DO NOT USE Zocor statin better than fenofibrate

Answer 101

glyburide - renally cleared Hg A1c 6.2 way too low for elderly pt - confusion, forgetfullness from hypoglycemia don't start any hypoglyc agent until pt cleared current drug (even insulin)

Answer 102

Rx to neuroleptic antipsychotic agents ie haldol muscle rigidity, hyperthermia, autonomic dysreg TX: d/c offending agents, IVF, GIVE BENZO (lorezepam) - cooling agents, BP agent ie nitroprusside D/C lithium If pt still needs anti psych - start low potency one AFTER 2 WEEKS then titirate up slowly ASA/tylenol not good with hyperthermia in NMS Succynly choline avoided druing NMS - r/o malignant hyperthermia - no good evid for NM blocking agents Only treat BP if still high after tx for NMS

Answer 103

61yo F pt with CV risk factors and h/o DVT NON-hormonal tx for hot flushes SNRI (venlafaxine, paroxetine) NOTfluoxetine or citalopram Never use hormonal tx on pt with DVT in past and not in women >60 Vaginal topical / vag tablets don't help vasomotor sx

Answer 104

pt was neg for CMV and got a CMV + kidney and now off acyclovir -> CMV diarrhea fevers/leukopenia in post tx period Dx: PCR or antigen other issues - diarrhea, PNA, encephalitis, hepatitis, GI ulceration, elevated LFTs CMV inclusion bodies on bx NOT cdiff - no leukopenia or elev LFTs Mycophenolate Mofetil - no fevers or elev LFTs can cause diarrhea/leukopenia Tacrolimus - can cause dairrhae but no fever, leukopenia or abn LFTs

Answer 105

aspiration, chockign coughing while swallowing - episode of PNA (presumed asp), Pt with ALS - painless wk atrophy and fasciculations beginning in ARM/leg - UMN signs hyperreflex, ext plantar responses, Bulbar onset ALS - dyphagia, slurred speech, NEED VIDEO FLOROSCOPY to assess swallowing foods of diff consistencies Not esophageal dysphagia (solids>liquids) Not esoph motility d/o (solids & liquids) No need for UGI series, EGD or manometry UGI series/EGD if suspected luminal issue (stricture/ring) Manometry if suspected motility d/o ie achalasia (dilated esoph on UGI series or EGD)

Answer 106

Excercise perfusion nuclear stress Age, sex, atypical chest pain -> stress test Need perfusion if baseline ST seg changes, greater than 1 mm ST dep, LBBB, pre excitation (WPW) Coronary artery Calcium score - surrogate for atherosclerosis, evaluates risk for cardiac event rather than prob of CAD utility in low risk patients 10-20% - CAC higher >400 need more intense risk stratification If unable to excercise pharm perfusion stress Adneosine/dipyrmadole - contraindicated in pt with broncospastic dz

Answer 107

Initial tx in pt without severe myositis or extramuscular manifestations (systemic sx, fever, wt loss, pulm, cardiac, GI sx) - high dose prednsione Gottron papules - pathomneumonic for Dermatomyositis erythematous violacious clumped papules over extensor surfaces of elbows, metacarpal joints PIP Fatigue, arthraliga, raynauds, nailfold capillary abn, cuticular hypertrophy, prox muscle wk, photosensitive rash, continue steroids x 4 weeks until CK comes down baseline bone density testing, ppx Ca/Vit D, bisphosphonates Also need phys/occ tx IVIG only if need more therapy other than steroid and contraindic to other immunosuppressives Use steroid + steroid sparing immunosupp (azathroprine/MTX) in pt with poor prog or extramusc manifestations)

Answer 108

Clinical features: macroglossia, hepatomegaly, nephortic syndrome, peripheral neuopathy, IgG lamda M protein evidence of clonal light chains in amyloid deposits Plasma cells in BM bx Need abdominal fat pad bx - if neg then affected organs (kidney, liver) need bx first check BM NOT ANCA vasculitsi - doesn't cause neuropathy or macroglossia Not Cryoglobinemia - nephrotic range protein and neuropathy but no macroglossia - lower extrem purpura

Answer 109

brown scaley, waxy - stuck on appearance - verruncus/warty features Horn cells (epidermal cysts filled with keratin) Atypical lesions can be bx r/o melanoma No tx needed - can remove for cosmetic reasons

Answer 110

red scaley macules in sun exposed areas PRECANCEROUS -> SCC easier to feel than see

Answer 111

Asymm, ireg borders, color variation, diameter>6mm, evolution Basal cell CA - have telangiectasias and look pearly

Answer 112

uniform brown scaley regularly shaped macules and patches - sun exposed areas - are themselves benign but denote extensive sun exposure so at risk for development of cancers and precancers in future

Answer 113

TEN - potentially lethal prodrome fever, sore throat, burning sensation in eyes 1-3 days before skin lesions Flat atypical purpuritic targetoid lesions-> coelesce into dusky poorly demarcated confulent patches - TEN with spots or confluent tender erythema without identifieable individual lesions (TEN without spots) BListers slough and leave denuded skin Skin pain two or more mucosal surfaces (eyes, genitals, nasopharynx) +nikolsky, >30% body epidermal detachment Etio - meds (antiepileptics, NSAIDs, abx, pantaprozole, sertraline,tramadol, allopurinol bactrim or infx - HIV, kidney dz, acitve autoimmune dz, human leukocyte antigen Within 8 weeks of starting drug Vessicles, bullae, erosions Bx won't distinguish SJS, erythema multiforme, and TEN survival improved when causative med stopped

Answer 114

acute recurrent mucocutaneous eruption, follows acute infection (HSV) can be drug related or idiopathic several MM to CM - erythematous plaques with concentric rings of color low grade fever NO LAD, EOS or inc LFS

Answer 115

Autoimmune blistering dz scaling and crusted lesions upper face, trunk erythroderma, +nikolsky - no mucosal inovlvement no epidermal detachement (aw TEN)

Answer 116

MC in children - adults with underlying immunosuppression or AKI affected too perioral crusting, and fissuring, - no skin detachment or muscosal invovlement

Answer 117

Acute decompensated HF and volume overload - give diuresis even if Cr high - AoCKD cause by renal congestion from volume overload - Cr will get better (not worse) with diuresis IV bumetinide Glomerular filtration rate inversely related to CVP (cvp up, GFR down) - poor prognosis with HF If extremely poor kidney fxn may not tolerate diuresis - will need HD Transfuse only if Hg really low (slight low value can be 2/2 fluid overload) Also additional blood will worsen volume overload If pt in low output state then milronone/ionotrope would be appropriagte Low dose dopamine in pt with AKI and HF doesn't have benfit

Answer 118

Inquire about dz that run in family more common ones (breast, prostate, colon, early CVD) Genetic counseling only if history c/w genetic suseptiblity, if will aid in medical or surgical management Send to genetics professional i fneed detail pedigre Don't screen for common genetic mutations unless clinical concern (high false positives, may be clincially unneccary - harm may outweigh benefit.

Answer 119

simple IDA - oral iron replacement just menstrating - IDA without GI or uterine dz fatigue, lack of sense of well being, dec'd exc tolerance, dec'd ET, h/a microcytic hypochromic erythrocytes anisopoikilocytosis (varied size/shape) high RDW mild thormbocytosis IV iron only with HD or pt not tolerating or absorbing oral Transfusion only if sx anemia where rapid correction needed for cardiac causes

Answer 120

If post prandial FSG too high increase rapid coverage pre-meal No need to add additional med - can oprimize current meds DOn't restrict carbs - pt underweight and tyring to concieve Don't change baseline insulin as premeals ok

Answer 121

If already on high dose PPI then next step is fundoplication First check for appropriate administration (30 min premeal) and compliance ->EGD to check for other caues (eos esoph, heart dz, acalasia) If EGD neg - 24 hr pH monitoring to determine if really GERD Inc'd PPI and sucralafate won't work Endoscopic antireflux surgery not needed (RF ablation)

Answer 122

``` Single dose IV ceftriaxone, 14 days doxy +-flagyl cervicitis and uterine tenderness=PID abd or pelvic pain with CMT, adnexal tenderness, uterine tnederness Cover Neiserria gonnoarhea, Chylamydia, aerobic gneg rods, anaeroboes Early f/u 72hrs Hospitalization if can't take oral Male partners tx'd ``` IV could be clinda + gent No cipro (gorrhea resist) Single dose ceftxx+azithro ok for cervicicits NOT PID

Answer 123

2/2 medication exposure, toxin exp, G6PD, mlaignancy, liver dz (linezold, tylenol, metformin, HIV meds) AG + inc'd serum lactate Lactic acid 2/2 tissue hypoperfusion No shock or hypoxia DKA - p/w +ketones - AG met acidosis, hyperglycemia, glucose >300, Pyroglutamate acidosis - critically ill getting tylenol - unexplained AG met acidosis Sepsis - not without wbc, fever, tachycardia

Answer 124

FEV1/FVC40, h/o tobacco or other exposure with dypnea, chronic cough or sputum FEV1>80% mild FEV1 50-79= mod FEV1 30-49=severe <30=very severe Asthma unlikely with lack of atopy, h/o resp sx as child GERD - not without some heartburn sx ACEi aw cough, not ARB

Answer 125

ectopic lens, aortic root dilation, lumbsacral dural ecasia fhx Long arms, long digits pectus evactium

Answer 126

ligamentous laxity, dramatic - velvety hyperext skin, atrophic scarring, no arterial aneurysms

Answer 127

aneurysmal diation of many bv's, ligamentous laxity, thin traslucent skin NO ectopic lens, skeletal abn

Answer 128

scholiosis, h/o fx, short, BLUE SCLERAE, dentinogenesis imperfecta (poorly developed teeth)

Answer 129

Face/Neck/under breasts/pannus - use weaker steroid - hydrocortisone valerate - less thinnig/atrophy Clobetasone=ULTRAPOTENT - don't use on face bethamethasone, desoximetazone - potent - don't use on face

Answer 130

uncomplicated otitis externa - 2/2 moist conditions otalgia, feeling fullness, +-hearing loss, pain with jaw motion, tendernesss with tragal or pinna tugging diffuse ear canal edema, purulent debris erythema GOOD TYMPANIC MEMBRANE MOBILITY tx: clear canal of debris ototopical agent (polymyxin B, neomycin, hydrocrotisone (mild - dilute acetic acid) ``` Allergic rxn to ear plugs - should not have purulent d/c Delayed hypersensitiety (IV) - erythema/edema with vesicles/bullae ``` Malignant otitiis externa - infection in ear speads to bone cartilage nearby - fever pain otorreha - appear much more ill Otitis media - no pain wth tragal/pinn atugging, middl ear effusion - eartyema of tympanic membrane

Answer 131

prevalence 8% Screen with cerebral artery MRA fhx known intracranial aneurysm (1st deg realtive) No need for 24hr protein if urine protein cr ratio already done No need for ADPKD genotyping No need for abd CT if ADPKD already dx'd

Answer 132

Dialtion of Common bile duct WITHOUT STONES on ERCP Not chollithiasis without stones visualized IBS - does not cause asc colitis dx'd clinically - no tests Primary biliary cirrhsois - dz of microscopic bile ducts = jaundice, fever, inflammation, liver inflammation, liver failure

Answer 133

Post coital abx ppx use cipro often aw spermacide use, liberal fluid intake, post coital voiding - if doesn't work the cipro chornic suppressive abx not as good cranberry juice doesn't work in studies Spermacide INCREASES RISK

Answer 134

Acute PE in pt with CKD and HD stable and oxygenating well -> UF Heparin + warfarin Thrombolytic therapy only if persistent hypotension LMWH + warfarin or fontaparinex + warfarin CONTRAINDICATED with CKD Argatroban + warfarin - used mainly for HIT (raises INR so hard to manage warfarin)

Answer 135

Retinal toxicity - baseline retinal exam and f/u needed used for SLE/RA depostion directly on retina Add TNF only if needs improvememnt Don't d/c MTX if working - unless LFTs inc Liver bx unnecessary

Answer 136

Sx: HTN, palpitations, sweating, h/a elevated plasma metanephrines/normetanephrien, elev urine catecholamines Tx: first with terazosin/ short acting Alpha blockers then surgery BB only after alpha blocker onboard ACE + arb no good effect Need to treat can't just observe

Answer 137

Pain crisis tx with MORPHINE (for all pts not just preg ones) + hydration, supp o2, opiates (not teratogenic) No hydroxyurea - teratogenic No ketorlac preg C No Meperideine - induces seizures

Answer 138

NO ASA - contraindicated 24hrs after TPA After TPA keep BP confirm with CT -> cryoprecipitate No benzo (diazepam) - benzos may impair recovery Don't give nitropursside - can inc ICP

Answer 139

Pt with sx of pain not attributable to cause and is angry emphatic support at frequent intervals ongoing discussion to discuss and understand potential causes and significance of pain Difficult encounters with pts depression/anxiety, poorer fxn status, unmet expectations, reduced satisfaction, greater use of healthcare services Time consuming, unrealistic demands, anger, don't follow recs, somatizaqtion d/o , chornic pain, substance abuse, undx medical problem Personality d/o (borderline, dependent, histrionic, obsessive, antisocial Dont just give pt pain meds without understanding etiology does not identify complex causes of sx or ID more appropriate therapy Dont just refer to specialist - they undergo unnecessary testing - Don't transfer care to another MD, need to recognize potential psych/emotional factors - MD also needs to understand own neg emtions about pt - helps to work collaboratively with patient

Answer 140

Don't intubate - poor outcomes with severe IPF Use NARCOTICS FOR PALLIATION Goal - reduce unnecessary suffering (remote likelihood of recovery DOn't give anti-fungals if no evidence of fungal infxn (neg sputum) acute exacerbations tx'd empirically with abx without knowlege of causative agent - when several days go by without improvement If already tx with steroids for several days high dose pulse steroids won't likely help Albuterol WILL NOT WORK - IPF not restrictive dz

Answer 141

unilateral ocular sx afferent pupillary defect contrast enhancement of optic nerve on MRI, white matter lesions, PERIVENTRICULAR Tx: high methypredisolone -> glatiramir acetate reduces risk of development of MS (also interferon beta) Acetazolamide - tx for idiopathic IC HTN - b/l visual changes, h/a, +papiledema - no contrast enahncement on MRI Migraine does not cause afferent pupillary defect or enhancement of optic nerve (can cause white matter lesions) Only watch and wait and MRI if NO white matter lesions

Answer 142

benign firm brown or violet brown papule - MC lower extrem, size of pencil head with button/dimple when lateral sides pulled together - arise from minor injuriese ie bug bites, shaving, folliculitis - DO NOT REQUIRE TX Epidermal inclsuion cysts - flesh colored SQ nodules with prominent central punctum filled with keratin Melanoma - darkly pigmented lesions - ABCDE - review! BCC - nodulear lesions, pearly, pink, waxy, , telengiectasic vessels Seborrheic keratosis - brown scaley, waxy papules/plaques stuck on appearance - verruncous/warty features

Answer 143

Stage III - risk factors male, barretts, GERD Barretts - columnar epithelium (like stomach) replaces squamous epithelium of esophagus -> inc'd risk of adenoCA Tx: surgery + periop chemo Radiation or chemo only is palliative - pt has potentially curable cancer

Answer 144

abnormal large mammory glands in man could be from imbalance of testosterone to estrogen ratio (low testosterone or high estrogen) Here if testosterone normal the CHECK ESTRADIOL Adrenal CT only if elev estradiol - and after testicular US to exclude testicular neoplasm - if neg then abd ct r/o neoplasm in adrenals Breast US only if unilateral dz, mass or assymetric growth karyotype only if LH was elevatetd and testoterone dec'd to r/o kleinfelters

Answer 145

Reynolds risk score Sex specific, Fhx, CRP - results in reclassification of a lot of intermediate to either low or high risk women Framingham - not as good in women - BP, chol, smoking, HDL, age QRISK2 - CV risk in pts in england and wales only SCORE for europeans CV risk

Answer 146

Large GI hemorrhage - h/o ASA use suggets GI source - IVF, blood, IV PPI infusion If still low bp give more blood and IVF intensive rescusitation reduces mortality After adequeate rescuitation - then EGD within 24hrs -can't do to inadequetely resucitated pt - also even mod sedation will cause hypotension Octreotide - known or suspected liver dz - used in variceal hmorrheage - decreases portal venous inflow and intravareceal pressure Don't do NG tube lavage (high false neg rate) and false + from NG tube irritation (can help localize bleed but not always) - hematemsis already shows large UGIB

Answer 147

Syphilitic chancre - SINGLE lesion, painless, border raised, cartilagenous consistency MSM Treponella pallidum RPR often neg in primary syphilis Also screen for HIV, gonorreha, chlamydia Chancroid - single or multiple PAINFUL!! ulcers with ragged border and purulent exudate HSV - mutiple PAINFUL ulcers - initially vesicles Human papilloma virus - GENITAL WARTS (not ulcers)

Answer 148

Urine findings cw glomerular dz - erythrocytes, acanthocytes (disfigured RBCs), RBC casts Rapid loss of kidney fxn over days, weeks, months Etio: antiglom basement membrane Ab dz, immune complex depostion (lupus nephritis), ANCA + vasulitis Glomerulonephritis: hematuria, oliguria, HTN, kidney insuff caused by glomerular inflamm U/A - hematuria, cellular/granular casts, proteinuria Sx: poorly controlled HTN, periorbital edema, LE edema - with RBC casts in urine

Answer 149

mostly pyruia, leukocyte casts no HTN, edema aw medication reaction

Answer 150

sustained ischemia or nephrotoxic agent | muddy brown casts

Answer 151

vasculitids of med sized vessels HTN, kidney insuff, kidney infrction bleeding hematuria/subnephrotic proteinuria NO RBC casts (no glomerular inflammation)

Answer 152

Pt with normal FSH, LH, not pregnant, gonadotropin, TSH/free T4, no hirusitism, acne, alopecia, clitoromeagaly, galatorrhea, no hot flushes, night sweats, wt chagnes, prior preg, fhx of thyroid dz or primary ovarian insuff Also had normal menstrual cycles Oligomenrrhea more common Serum FSH>35=primary ovarian failure, 20-35 = low ovarian reserve FIRST TEST - progesterone withdrawal challenge: determines if making adqueate estrogen - progesterone should make bleed - if not, low estrogen state - likely hypothalamic or pituitary cause given normal FSH If signs of hyperandrogenism (hirsuitism, virilazation clitoromegaly, voice deeping) - check testosterone and DHEA No MRI as prolactin and FSH normal Asherman syndrome - endometrial scaring as cause of 2ndary amenorrhea - h/o D&C or uterine infection - would need pelvic US

Answer 153

with 2nd or 3rd deg block - tx with IV ceftriaxone (confirmed serological lyme) if sx then hospitlaization for cardiac monitoring Asx patient with 1st deg AVB - oral doxy or cefuroxime No PPM as likely is reversible with tx of lyme Need to treat not just observe

Answer 154

unilateral, throbbing, photosensitivity, nausea 4-72hrs (ddx from cluster as >3hrs) (DDx from tension as severe and with n/photophobia) PPX: amytryptiline (TCA), topiramate, divalproex, timolol, propranolol DO NOT USE BB (timolol, propranolol) with h/o asthma No evidence for fluoxetine or other SSRI in migraine prev Verapamil -> prevention of CLUSTER h/a Mg/Riboflavin (B2) ppx for h/a, NOT Vit D

Answer 155

AG metabolic acidosis + resp alkalosis DDX salicylate toxicity, liver dz, sepsis Can get salicylate poisoning from oil of wintergreen (in homeopathic creams) MS change, n/v, fever, tinnitis No osmol gap Methanol toxcity AG met acidosis with osmolal gap - would have an osmolal gap but NO RESP alkalosis No sepsis - no signs of fever, normal serum lactate, no hypotension, no WBCs Metformin toxicity - SEVERE lactic acidosis in pt with AKI in seting of critical illness or following acute OD - normal lactate would r/o this

Answer 156

abnormally low body weight with fear of gaiing weigh (t solve problem of anorexia nervosa

Answer 157

Pt dyspnic at rest, O2 sat 86% off O2 - ADMIT TO HOSPITAL Severe dz, advanced age, significant comorbidieis, inc'd intensity of sx, new arrythmias - insuff home support, failure of initial med management Needs hospital for O2, abx, steroids, inhaled broncodilators Home O2 would not work - resting hypoxia shows lack of improvement don't just broaden abx - needs hospital for agressive management don't just use steroids - needs other care in hospital

Answer 158

D/C MTX 3 months prior to conception attempt MTX VERY teratogenic (cat x along with leflunomide) advisable for men to d/c as well Women in preg usually get spontaneous remission of RA in 2nd trim - if not then ok to use low dose prednisone, hydroxyclorooquin (retinal exam) or sulfasalazine Avoid NSAIDs in 3rd trim - premature closure of PDA, interference with labor Resume post partum unless breast feeding as dz flares post partum

Answer 159

Tx: corticosteroids Painless jaundice with diffusely enlarged pancrease, narrowed pancreatic duct - mass r/o by CT and EUS, normal CA-19 r/o pancreastic CA Elev IgG4 = autoimmune pancreatitis If do not improve in 3 months, consider other dx If relapse with steroids try immunomodulator (azathroprine) No Abx (only for ascending colangitis or infected pancreatic necrosis) - pt not febrile No need for biliary stent as most strictures respond to steroids in AIP No reason for whipple with AIP (for pancreastic cancer)

Answer 160

Indications for replacement 1. Very severe stenosis - mean gradient >60 2. LVEF <50% 3. Rapid progression of stenosis 4. exc related hypotension or sx 5. Other cardiac surgery needed (CABG) If none then repeat TTE in 12 months (interval exam 6 months) Balloon Aortic Valvulopasty in hemodynamically unstable patients as bridge to AVR (r/o stroke, MI, death) Dob stress - if low flow, low gradient with severe LV dysfxn - do dob stress - if LVEF improves then possible AVR (or if gradient improves)

Answer 161

``` vasc pereforation -> intestinal perforation -> abd pain, free air on xray targets EGF on vasular tissue HTN poor wound healing bleeding, thrombosis ``` 5FU s/e - diarrhea/mucositis (no perfs) Oxaplatin - neurotoxicity, distal sensory neuropathy Typhilitis - neutropenic enterocolits - complication of myelosupp chemo - fever abd pain - NO PERF

Answer 162

Atrial tachycardia - adenosine slows or blocks AV node but will see rapid p waves on EKG while AV node blocked Adenosine will terminate AVNRT and AVRT as it interupts circuit - if adenosine fails to terminate SVT then likely not AVNRT or AVRT Tx for Atach - BB or CCB first If not then IC or III antiarrythmic If that doesn't work then RFA (less succesful as multiple foci)

Answer 163

small incidentally found carcinoid - well differenctialed within appendix when taken out - curative No Indium-111 scan - see's somatostatin expressing tumors but if CT is neg for other abn no need in setting of small appendeceal tumor Octreotide - somatostatin analog for management of hormonal sx of neuroendocrine tumors when present and can slow metastatic carcinoid no role in post resection adjuvant tx of localized and resected neuroendocrine tumors Large carcinoid tumors - with more aggressive histology - right hemicolectomy - clear local LN Streptozosin + 5FU - antitumor activity in pancreatic neuroendocrine tumors

Answer 164

Pt is NYHA I - drug evaluated in NYHA III/IV - pt's HF too mild to take drug (not geenralizable to NYHA I) and derive benefit RCT gold standard cuz allows confounding variables that might obscure benefit to be balanced between groups usually restricted to very homogenous group with rigid inclusion/exclusion criteria - makes conclusions narrow and not very generalizable (ie pt with NYHA III/IV benfit but can't extrapolate to NYHA I) Pt's are balanced in RCT with or without co-existing meds - can't be sure if taking or not taking BB in addition to exp drug will affect seeing benefit No arbitray adverse event cutoff - need to consider risk vs benefit Use caution when generalizing results of RCT to pts outside of inclusion/exclusion of trial

Answer 165

episodic abd pain, n/v, +marijuana use aw compulsive washing (ie relieved with baths) Tx: cessation of marijuana use Cyclic vomiting syndrome: acute episodes of vomiting for up to a week, 3 or more episodes in 1 year, absence of n/v in between - personal or fhx migraine supportive -> if cannabis use then Cannoboid hyperemeis syndrome more likely Gastroparesis usually daily sx in setting of long standing DM Chornic intestinal pseduoobstruction - abd distention, pain, nausea sometimes vomiting, acute, chronic or recurrent, - dilated small bowel - absense of true obstruction - can be caused by neuropathic d/o such as DM, amyloidosis, paraneoplastic, , myopathic - dx made by gastric and small bowel manometry

Answer 166

``` Pt with known risk factors and HIV + PCP PNA is most common Opp infection subacute dry cough, dypnea diffuse interstiial dz on CXR PO2<50 - fever, night sweats, wt loss - inovlve liver, spleen, LN but NOT PULM DZ ``` Candida is RARE cause of PNA - pseduohyphae on sputum liekly from candida

Answer 167

when treating central hypothyroid NEED TO TREAT for progressive adrenal insuff with GLUCOCORTICOIDS (hydrocortisone) if cortisol low or low normal Central hypothyroid - low Free T4 but inappropriately normal or low TSH If you treat central hypothryoid first then metabolism revs up an uses up little cortisol reserve and goes into adrenergenic shock Don't need to treat low testosterone or low GH yet Don't need vasopressin if no signs of (central) DI

Answer 168

``` aw episotic hand inflamm attacks one or two joints usually inflammed osteophytes and joint space narrowing on Xray (diff than polyarticular attack in RA) +bouchard (PIP) + heberdens (DIP) central erosioins or cystic changes mildly elevated ESR/CRP ``` Psoriatric arthrtisi - DIP - absnese of rash does NOT rule out inflamm of tenosynovial jnc - cuases inflamm beyond joint (sausage digits) - more desrtuctive than hand OA Tophaceous gout would have tophi depostis Late onset RA - need to look for MCP invovlement to rule in RA vs OA and change in pattern of arthritis

Answer 169

Sx and spirometry COPD - in young pt | FEV1/FVCd

Answer 170

thunderclap h/a recurrent over a few days or weeks in association with transient cerebral vasoconstriction severe an explosive Need cerebrovascular imaging r/o SAH no abn on neuro exam Tx: CCB may present during pregnancy or peripartum Don't do MRI brain Indomethacin for specific variations - aw cough, exertion, sexual activity Sumatriptan - acute migraine

Answer 171

aka pitriaysis versicolor superficial fungal infection of skin yeast - Malassezia furfur Spores/hyphae from scraping KOH - spagetti and meatballs tx: Topical ketoconazole, bifonazole, miconazole, clotrimazole Oral azoles only for recalcitrant tinea versicolor or very extensive making topical agents impractical drug interactions and abn LFTs Don't use topical corticosteroids - relieves pruritis temporarily but makes infection WORSE - allows yeast to flourish

Answer 172

FNA thyroid nodules benign vs malignant FNA at least 5mm with worrisome sonographic character (fhx, hypoechoic, cystic, microCA, central vasc, blurred margins) Don't just watch pts with suspicious features Thyroid lobectomy - only if cancerous <1cm MRI less useful - only for local extension

Answer 173

Surgical tx and infliximab Fistula - abn conn between bowel and adj organs fecal matter thru skin drain abscess - start infliximab Simple fistula: superficial, single opening, no abscess, no rectovaginal fistula, no anorectal stricture, tx: Cipro/flagyl Do not use steroids

Answer 174

``` resect all resectable dz intravesicular BCG immunotx (Stage I invading mucosa only) reduces local recurrence surveillence - repeat cytology/cystoscopy q3m ``` Radiation - only if invades muscle CYstectomy - for CA that invades muscle, bladder CA in situ recurring after resection + BCG or INCOMPLETE resection DO not just observe

Answer 175

``` If inc'd RV pressure on TTE -> RHC neck vein dilated, RAD, prom central pulm veins, clear lungs, dil RV elev RVP, V/Q normal prom pulm compoent S2 r/o OSA Can also test response to vasodilators ``` Clear lung field with pulm sx out of proportion r/o lung dz - no need for HRCT No need for pulm arteriogram - VQ scan normal - rules out chronic thromboembolic pulm HTN No sx of OSA - no need for sleep study TEE won't add anythng new

Answer 176

LVEF 120 already on OMT (BB, ACEi, spironolactone) decreases mortailty, sx, HF hospitalization improve LV syncorny by coordinating septal and lateral wall contraction No single/dual chamber ICD - RV pacing would be harmful NO bivi pacing only as needs ICD too

Answer 177

Critically ill patients pseduomonal coverage Cefepime, tobramycin, azithro antipseudomonal B lactam with pneumococcal coverage (cefepime, impipenum, meropenum, zosyn) + cipro/levo or antipseduomonal B lactam + aminoglycos+azithro or antipseduomonal B lactam + aminoglyc+resp quinolone Aztreonam replaces B lactam Risk factors for pseudomonas frequent exac of COPD, long standing corticosteroid use

Answer 178

Plan for pre-tx PD If healthy, otherwise independent, no abd surgery can't wait a year for genetic identical kidney don't use cadaveric - less allograft survival than live donor don't start pre-empitve dialysis - doesn't help

Answer 179

autoimmune inflamm d/o cartilage of nose/ears (boxer ear, saddle nose def) RA like polychondritis Check Pulm flow volume loops - cartilagenous tracheal rings of larynx, trachea, bronchi - obstructive findings on flow volume loops Not granulomatosis with polyangiitis as neg ANCA, no sinus dz No RF Utox only if suspect cocaine induced nasal septum damage

Answer 180

herpes zoster opthalamacus - urgent acylocvir, valcyclovir or famcyclovir and opthal consult Can lead to blindness ``` usually single dermatome and doesn't cross midline Hutchinson sign (eruption on nose) not predictive of eye invovlement ``` no warm compresses or abx for viral infxn never use steroids as single agent for herpes zoster if needed in conjunction with antiviral by specialist

Answer 181

keratoconjuntivitis sicca, xeroophthalma, xerostoma - difficulty chewing and inc'd peridontal dz vaginal dryness, parotid enlargement inflamm polyarthritis, cutaneous vasculitis, mononeuritis multiplex, distal RTA, interstitiial nephritis Pulm involvement - Interstitial lung dz Schrimer test - moisture under lower eyelids ANA+, RF+, Anti La/SSB xerostomia/xeroopthalimia/Anti ro/SSA/Anti La/SSB + abn schrimer = 94% sensitive for Sjogrens Meibomianitis - dysfxn of meibomian glands that make lipids for tears Both RA/SLE would involve systemic sx (arthritis, pleuritis, cerebritis, lung dysfxn, skin changes also

Answer 182

Soitary pulm nodules = < 3cm surrounded by normal lung no LAD Lung mass=>3cm Low risk individual with t detect)

Answer 183

continue to make decision for pt cw previously expressed wisihes and values - "what would they do?" (substituted judgement) If pt presents to ED without ability to express desires - emergency care is under IMPLIED consent - but once wishes known do not do what they woudl NOT wnat to do No court appoitned guradian if pt expressed his views and subsequent decsions made by duly appt'd surrogate Do not try to change decisoin of duly appt surrogate

Answer 184

S. pneumoniae, Listeria monocytogenes - Empiric abx - vanc, ampicillin, 3rd gen ceph (ceftriaxone, cefotaxime) + dexamethasone (attenuate release of bacterial virulence component from lysis of bacteria) may limit inflamm s/e from meningitis (cerebral edema, inc'd ICP) - give with 1st dose of abx Only add rifampin if suseptibility shows sensivitive Ext ventricular drain only with hydrocephalus Repeat CSF only if have not impvoed in 36-48hrs

Answer 185

Memory loss that does not interfere with social/occupational fxn does NOT indicated dementia - requires no further eval and tx (short term memeory - recall names, faces, location of placed objects) MMSE does not indicate dementia Mild Cognitive impairment - loss of cog ability that exceeds age related memory loss and DOES interfere with - 10-15% ppl with MCI meet dementia criteria w/in 1 year If evidence of dementia or head trauma - need MRI/CT apolipoprotein E4 = alzhemiers risk - no sx so no testing No neuropsych testing if no fxn abn Donezepil - improves cog fxn in pt with mild, mod or sev alz dementia - no role in age related memory loss or MCI

Answer 186

Rheum arthritis Morning stiffness >1hr and synovial fluid count >5K = inflammatory arthritis symm swelling of PIP, elbows, ankles - can also affect most joints lumbar/thoracic spine and DIP spared Usually symmetric, small joints of hands/feet h/o non-inflamm back pain If pt with inflamm back pain with new periph inflamm artritis - w/u for spondyloarthris or psoriatric arthritis Fibromyalgia - widesspred chronic MSK pain at least 3 months - women 20-50, PE normal excespt widespead pain/tenderness - no active synovitis OA - hip, knees, , lubar/cervical spine, PIP/DIP - asymmetric - no typically abrupt and simulantous (no elbow/ankle invovlement unless prior trauma) Polymyalgia rheumatica - aching shoudlers, neck, hip girldle area - fatigue, malaise - weeks to months

Answer 187

urine alkalination with potassium citrate allopurinol (XO inhibitor) Pt typically with low urine volue and hyperuricosuria (high protein diet), tumor lysis - gout, DM, metabolic syndrome, chronic diarrhea Get pH>6 limit protein Don't use aceetazolamide - can alkalayze urine but -> metabolic acidosis CaCarbonate for Ca Ox stones to dec oxalate absorbtpion Don't use HCTZ or chloritalidone - increas serum uric acid - inc propensity for gout

Answer 188

Wilson's dz Young patient with acute liver failure (high INR, high AST/ALT) hemolytic anemia, high retic ct, large fraction unconjugated bili low alk phos Zinc is cofactor in alk phos production - copper is competitive inhibitor of zinc - reduced alk phos prodxn Referal for liver tx Near 100% mortality without tx Acetaminophen toxicity - pt h/o tylenol use and urine metabolites - no hyperbilirubinemia OR hemolytic anemia Acute viral hepatitis - hep A or hep B +, (Ab to hep B shows immunity to hep B and IgG to hep A means past infxn and immunity to hep A) Primary biliary cirrhosis (PBC) - DOES NOT presents as acute liver failure - pressentation progressive clinical decline - has CONJUGATED hyperbili, ELEVATED alk phos from inflamm of bile ducts in PBC

Answer 189

Tx for COPD Tiotropium, budesondie/fometrol inhaler, albuterol as needed - tapered prednisone after exacerbation +Roflumilast - oral PDE-4 inhibitor (for pt with severe and very severe COPD with frequent exacerbations) Strong anti-inflamm but NOT brocodilator (not for acute exacerbation) - shows modest inc in FEV1 S/e - diarrhea, wt loss, n, headache, backache, depression, dec'd apetitie, dizziness, occ neuropsych sx (depression/suidcidaltiy) No long term oral corticosteroids - limited benefits adn many side effects (osteoprosis, glaucoma, adrenal suppresion) No O2 unless < 88% PO2t show improved lung fxn or clinical outcomes in pt with stable COPD or acute exacerbation

Answer 190

Dypnea, enlarged right heart, fixed split S2 - inc'd murmur of RVOT (soft systolic murmur 2nd L ICS inc'd with resp), mitral regurg (holosystolic murmur at apex no change with resp), LADev, RVH, parasternla impulse, tall A waves, c/w osteium primum asd with associated mitral cleft adn MR Aortic coarctation - early systolic murmur, occ diastolic murmur, - HTN, pulse delay upper to lower extrm, figure 3 sign on CXR - collateral flow around ribs Pulm Valve stenosis - early systolic murmur 2nd left ICS, pulm S2 split (varies with deg of stenosis) - NO MR, EKG RADev, RVH Small perimembranous VSD - loud holosystolic mumur with thrill, moves into S2 (normal S2 - no pulm HTN), no EKG abn, CXR ab

Answer 191

Repeat testing in 6-12 months 2.5 cm mass no clinical (HTN, elect abn, glucocorticoid excess)/biochemical signs of excess hormone secrtion of glucocorticoid, mineralocorticoids or adrenal androgens, or catecholamines Size < 4cm, housfeld <20 units not suspecious for malignancy - Pt with early pheo or cushings may have no clinical manifestations - always screen for both with any indicental mass, (urine metaneph, low dose dexamethasone suppression) hyperaldo screen - serum aldo to renin ratio no MIBG - hunt for pheo - if not HTN or biochem excess of catecholamines MRI not needed No indication for surgery for incidental non fxn mass that is small

Answer 192

Limbic encephalitis subacute memory disturbance, personality change, psychosis, enceph, seizrues, oral dyskinesia (invol mouth movmements) aw ovarian teratomas Prodrome = flu like illness FLAIR MRI - temporal lobe enhancement CSF - mild lymphocytic pleocytosis, normla protein Anti-NMDA rct ab in serum or CSF Tx: early oophroectomy, plasmapheresis, IVIG or corticosteroids

Answer 193

motor or sensory sx limbic encephalitis in 20% aw small cell lung CA Anti-Hu autoAb

Answer 194

``` limbic encephalitis memory disturb, seziures, psychossi In immunocompetant - more acute presentsion fuliminant sx over DAYS +fever no oral dyskinesia CSF lymhocytic pleocytosis with or w/o elev protein (CSF can be normal) +erythrocytes in CSF MRI flair in temporal lobes PCR CSF for herpes empiric tx with acyclovir ```

Answer 195

inflamm of covering of brain (not parenchyma - encephlaitis) no memory disturbance, psychosis, seizures - CSF with lymphocytic pleocytosis MRI enhancement of MENINGES not parenchyma

Answer 196

At least 1 month of sx including intrusive thoughts about event - , nightmares, flashbacks, avoidance of reminders of event, hypervigilence with sleep disturbance (sx in all three areas - re-expeeriencing event, heightened arrousal, avoiding reminders of event) Co-morbid conditions - depression, anxiety, substance abuse, Tx: CBT, -cognitiviely reframing thinking patterns and gradually re=exposing pt to truamatic event, stress management, SSRI

Answer 197

excessive anxiety and worry about VARIETY of events or activities fo rat least 6 months - difficulty controlling worrying, h/a, nausea, trembles, - ususally not particular inciting event

Answer 198

5 or more of 9 cardinal depression sx in 2 week period one shoudl be depressed mood or loss of interest/pleasure change from prior fxn, with sig clinical distress/imppairment fxning

Answer 199

recurrent obessesion/compuslions at least 1hr per day - marked disterss/impaired social fxn Obsession - persistent thoughts, impulses, images - intrusive, aw anxiety/distress Example: fear of leaving doors unlocked, germophobia Compulsions - repetitive behaviors - ie handwashing, checking, ordering, coutning - repeated to dec anxiety from obsessions

Answer 200

Significant dyspnea with stridor and reduced inspiratory and expiratory flows without improvement with inhaled broncodilator Fixed airway obstruction: flattened inspiratory AND expiratory volume loops (exp top, inspir bottom - alphab order) Likely 2/2 tracheal stenosis from prolonged intubation Dx: with CT (ie virtual bronch) or direct inspection from flex bronch Not c/w asthma exacerbation - low FEV1, NO reduction in inspiratory flow, improvement with broncodilators - no corticosteroids needed Lung volume measurement not needed - shows dec'd TLC since pt unable to take full breath 2/2 tracheal stenosis, - no evidence of fixed airway obstruction Voice/speech therapy not needed - only for VCDysfxn VCD - more inspiratory wheezing, heard over neck No reduction in FEV1 Flow volume loops - preserved exp loop (top), flattened inspiratory loop (bottom)

Answer 201

Nitrofurantoin x 5 days if sulfa allergic (normally use bactrim if < 20% local resistance) DO NOT USE IF PYLEO suspected Don't use amoxicillin or ampicilin - high freq of E coli resisance unless shown to be susceptible Fosfomycin - inferior and not to be used if pyelo suspected Flouroquinalones (levofloxacin) alternative for pts intollerant to first line agents or live in areas that >20% resistance to bactrim - should only use in more serious infct than acute cytitis

Answer 202

No treatment for asx chondrocalcinosis - manifestation of calcium pyrophosphate deposition dz (CPDD) - crystals deposit into cartilage - or released into joint - acute PSEUDOGOUT - Deposits in cartilage of wrist and knee HypoPhos, hypoMg, hypothryoid, hemochormatosis, hyperPTH, - shoudl be screened and tx'd for udnerluing conditions Tx with NSAID, corticosteroids, colchicine for reducing inflamm but not needed if asx (elec abn ruled out, thyroid ruled out) No way to alter deposition process INtraarticular hylaurine injection no benefit vs NSAIDs even though levels decreased in OA

Answer 203

Autoimmune dz with well defined round smooth area of hair loss with preserved follicular openings Onset abrupt and occurs in younger otherwise healthy pts No inflamm or scale (unlike other allopecias) Hair at periphery easily extracted - tapering pencil point fx Nail pitting Spontaneous resolution Personal/fhx autoimmune d/o (ie hashimotos)

Answer 204

gradually over years | hair thinning in crown and temples

Answer 205

allopecia in well defined pathches - with inflammation, scaling and dyspigmentation

Answer 206

diffuse hairloss in months after pregnancy or surgery - isolated areas of diffuse allopecia not seen

Answer 207

fungal infection of scalp - well demarcated area of allopecia - PROMINENT SCALE +- erythema

Answer 208

Opiod analgesic constipation micro opiod rct antagonist - methylnaltreoxone - helps with constipation s/e without reducing anlagesia Naloxone - tx of opiod OD - counteracts neg effects of respiratory depression and central nervous depression Diatrizoate sodium enema - could help pt if not respondin gto other measures Don't just decrease morphine - inadequate pain control

Answer 209

multiple extranodal sites - bowel/BM Oveerexpression cyclin D1 and t(11;14) translocation worse features of both indolent and agressive lymphomas - incurrable - (like disseminated indolent lymphoma) but shorter mean survival - Diffuse B cell lymphoma can invovle multiple organs but no cycliln D1 Follicular lymphoma NO BOWEL infovlement and no Cycline D1 Sezary syndrome - cutaneous t cell lymophoma - skin invovlement = mycosis fungoides - patchy areas to diffuse erythroderma range - infection of skin lesion - sepsis NO bowel inovlvment

Answer 210

MCC nephortic syndrome in Black patient nephrotic syndrome, microscopic hematuria, HTN, kidney dz, high chol, severe edema, low albumen Secondary cuases = processes causing glomerular hypertrophy and hyperfiltration (toxin, infection, atheroembolic dz) but seondary with mild edema, Bx: scarring/sclerosis of some glomeruli IgA nephropathy - white/asian (rare in blacks) immediately after URI, normal complement microscopic or gross hematuria proteinuria mild - rapid kidney faiulre rare Deposits of IgA in mesangium on immuno study Post infectious glomerulonephritis - several weeks afer strep/staph infxn - from immune complex dep on kidney, low complement - nephritic syndrome

Answer 211

Elective surgeries shoudl be postponed at least 1 year of DAPT after DES DES - at least 1 year of ASA plavix prior to elective surgery BMS - 4-6 ASA plavix Even after 1 year still risk of late stent throbosis likely from hypercoag period post op Don't just proceed to surgery on DAPT - may cuase throbmosis 2/2 hypercoag period after surgey = no reason to rush as surgery elective UFH/ LMWH does not prevent stent thrombosis

Answer 212

Hand washing with soap and water for at least 15 to 30 seconds or etoh hand hygene alternatives - also barrier precautions, gloves, protective equipment, transport of contaminated linen Bleach to clean rooms for c diff but not acinetbacter PPx antibiotic not as effective as proper hand hygene, +resistance removing contaminated drain/catheters does not prevent spread to other patients

Answer 213

combination drug therapy for stage 2 HTN >160/100 In pt age < 140/90 If >20 mm SBP need multi drug Lifestyle mod - exc, reducing etoh, will not lower 20mmHg Monotherapy won't lower SBP 20mmHg Need to initiate therapy after 2 subsequent high readings

Answer 214

movement d/o ill defined discomfort or dysethesia invovled with legs when trying to fall asleep coupled with urge to move 20's to middle age Familial Tx: dopamine agonists or opiates (codeine) Also with periodic limb movement - can be confirmed in sleep study disturb partner sleep can be aw iron deficency - check ferritin both caused by dopamine def Tx: dopamine agonists ie pramipexole or ropinrole Akasthesia - restless coupled by urge to move but no dysethesia or or periodic limb movements - generalized sensation not limited to legs Nocturnal leg cramps - sustained muscle contx in calves, Nocturnal myoclonus - limbs jerk suddenly as trying to fall asleep

Answer 215

Xray back Spine fx happen even with minor truama in AS ossification of vertebral disk -> rigitidty-> dec'd ability to dissapate energy - >low mineral density -> easy fx No prednisone for AS - bone loss and fx risk Change to another TNF alpha in same class if recurrent symptoms - Epidural steroid inj - radicular pain - no benefit in spinal stensosi or non specific back pain

Answer 216

CHECK DIG LEVEL regularized ventricular rate in pt with afib taking dig=dig toxicity coarse afib with regularized ventricular rate =complete heart block with ventricular escape (this is why its regular) (also sinus arrest, atach, jnc tach, av block, PVC, VT) N/v, fatigue, vision abn, MS change Dig cleared in kidney so with AKI/CKD tox more probable DCCV only if afib with sx Only TVP or dob if bradycardia is cause of sx (with good BP and HR in 40s likely not) DIG cannot be removed with HD Need digibind Also aw hyperK+ as interferes with K+ pump into cells

Answer 217

Nuclear schintography - technictum - if pt has low bleeding rate (1mL/min If HD stable and requiring blood only q3day likely not bleeding at this rate MR enterography/CT not good for vasc blleeds only if there is RP hematoma (extraintestinal) Small bowel barium enema - ID mass or crohns not bleed

Answer 218

``` Difficult to control asthma and h/o recurrent pulm infiltrates Consider ABPA Elev IgE, +EOS Aspergillus fumigatis Central bronciectasis - chest CT Check allergic skin test for Aspergillis ``` No use for bronch at this point unless reason to believe has superiposed OI or alt dx Sputum gram stain can't make dx of ABPA Sweat testing if suspect CF - not likely given older age, no extrapulm sx - clubbing/ GI sx

Answer 219

R adrenalectomy Tumors >6cm -> should be surgically resected High attenuation should be resected (suggestive of malignancy) Whether or not fxnal Don't just bx - no need No need for 24 hr urine cortisol or Serum renin aldo ratio

Answer 220

>18yo screened for HTN q2yr for those with BP < 120/80 | Yearly screening for preHTN (120-139/80-89)

Answer 221

Minimize risk for alloimmunization using PHENOTYPICALLY MATCHED blood C, E, K antigens and antigens already developed avoid delayed hemolytic transfusion rxn Need to get pt to Hg 10 to avoid Acute chest syndrome HbS neg blood decrases risk for vasoocculisve crisis but not alloimmuniz Irradiation dec's risk of graft vs host dz, not alloimmuniz Washed PRBC dec's risk of allergic rxn (IgA def) but not alloimmuniz

Answer 222

Reduce frequence with both allopurinol AND colchicine Gout - acute intermittent attacks of severe pain, redness, swelling of joint with intracellular crystals seen in polarized light - NSAIDs, colchicine, steroids for acute attacks Use of urate lower agent inc'd short term r/o gouty attack for ppx with cochcine approparitae as well Reduce fructose adn purine intake, dairy, wt loss, etoh consumption D/c urate inc'ing meds ie HCTZ, salicylates Febuxsat MORE EXPENSIVE colchisine only would not address underlying urate deposition

Answer 223

ceftriaxone and azithromycin coinfection with gonorrhea and chlaymdia intracellular diplococci - Don't just use high dose azithro Don't use cefoxitin - won't cover chylmdia Don't use cipro - gonorrhea resistance

Answer 224

most pt's with diarrhea have self limited gastroenteritis No testing or tx needed work contacts sick with similar sx Additinal eval if: fever, bloodly stools, elderly/immunocomp, hosptialization, food handler, recent abx use, , volume depletion, significant abd pain Well hydrated, loperamide C diff if recendt abx use Fecal leukocytes rarely helpful Flex sig only for persistent watgery diarrhea r/o microscopic colitis

Answer 225

Check for pancreastic autoab - Islet cell ab or glutamic acid decarbosylase Ab If + then DM1 - will start insulin right away If - then DM2 - lifestyle modification/metformin No need to check c-peptide - pt obese with hyperglycemia and no ketones is making insuliln - c peptides fasting or daytime and insuli will all be high

Answer 226

``` Ibuprophen erythema infectiosum Schoolteach (elementary) polyarthralgia, flu like sx, slapped cheek rash IgM + parvovirus B19 (IgG past infection) NSAIDs for joint pain and fever ``` Azithro and PCN for bacterial infections Strep - Rheum fever - migratory polyarthritis/fever, erytehma marginatum - evananecent pink macular rash on trunk adn limbs NOT face - expands outward, clears inward, antistreptolysin O + Hydroxychloroquine - lupus/RA - low ANA and RF can be seen during parvovirus B19 infxn

Answer 227

contraindication for non inv ventillation: resp arrest CV instability high asp risk copious secretion recent facial or gastreoesophageal surgery craniofacial trauma or nasopharyngeal abn burns extreme obesity NO nitro with hypotension Pulm catheter placement only in certain patietn to address hemodyamics

Answer 228

Bedside vital capacity - assess impending resp failure in pt with NM weakness - along with negative inspiratory pressure Serial ABG not good enough CXR doesn't tell enough Rapid shallow breathing index - predict if patient can be successfully wheened

Answer 229

If found on CT - get kidney US to determine cystic vs solid If US -> simple cyts, no further eval If US-> not simple cyst - CT with contrast (check for local LAD, invovlement of renal vein) Do not bx if >3cm Do not wait for f/u 6 months for masses >3-4cm - highly suspicious No reason for MRI

Answer 230

Zosyn initially Change to ampicillin - good narrow spectrum agent for sepsis Nitrofurantoin - not absorbed in bloodstream well Zosyn, imipenum, cipro too broad - need to descalate

Answer 231

assess tob use at every visit advise smoking cessation assess interest in quiting assist with medication FIRST SEE IF INTERESTED in quitting

Answer 232

Mucopurulent cervicitis elev pH, leukocytes, neg whiff test Gonorrhea/chylmydia Tx: 250mg Ceftriaxone and azithro 1gm x1 ``` (Cefixmime alt for ceftx but also need azithro or doxy for chlaymidia) No flouroquinioones (cipro) for gonorrhea (resistance) ``` Cefoxtin + doxy - PID tx (+adnexal, CM or uterine tenderness)

Answer 233

Start with kidney US esp if fhx kidney dz - may be genetic (r/o obstr, echogenic small kidneys, polycystic) CT only if can't US Kidney bx only if glomerular dz or kidney tx dysfxn Radionuclide scanning - expensive, limited availablility not needed with accurate GFR equations

Answer 234

combined UMN, and LMN signs and sx - no pain UMN - spasticity, inc'd tone, hyperreflexia, patholic reflexes LMN - fasciculations, atrophy, decreased tone, hyporeflexia (pt has brisk reflexes of upper arm with muscle atrophy/fasciulations of LOWER arm) Carpel tunnel - no UMN signs - sensory and neuro sx - wk of thenar muclses Cervical radiculopathy - no HYPERreflexia (UMN) Neuralgic amyotrophy - inflamm of brachial plexus - severe pain in distribution of brachila plexus - winged scapula

Answer 235

chornic vasculitis of AORTA and major branches inflammatory dilation/stenosis of major aortic vessels h/a vertigo, visual impairment, renovascular HTN Age 10mm in UE Aortic dissection would be more acute

Answer 236

small and med vasculitis of hands/feet SMOKING MEN

Answer 237

Coronary artery aneurysms, NOT large vessel

Answer 238

Do not perform during acute thrombotic event OR during warfarin use or on blood from right before initiation of warfarin Perform 2-4 weeks after cessation of warfarin (active thrombosis alters levels of protein markers) Warfarin also dec's protein C/S activity, inc' AT3 activity activated protein C resistance, FV Leiden, prothrombin gene mutation, antiphospohlipid Ab, lupus inhib, protein C/S def High risk - first VTE <50yo, recurrent, 1st deg relative VTE before 50

Answer 239

Fhx kidney dz with b/l kidney cyts Angiomyolipomas of skin, retina, kidneys, other organs cognitive impairment, dec'd visuion, cystic lesions kidney Ash leaf spots (hypomelanotic macules), dental abn (pits on dental enamel) Need kidney US at dx and q1-3 years ARPKD massive kidney enlargement at birth Fabry dz - X linked d/o alphagalactosidase - NOT cystic dz, nephrotic range proteinuria, cutaneous angiokeratomas, painful parathesia hands

Answer 240

>6 months - yearning for loved one - other desires incapacitiated Anticholingeric drug s/e - acute confusion/halluc Generalized Anxiety d/o - excessive worry and anxiety of a variety of events - anxiety, fatigue, restlessness, sleep disturbance, fxn impairment Major depression with psychotic fts - pt aware that they are not real (wife is really not there) - true psychosis pts believe they are real

Answer 241

daily spiking fever, salmon colored rash, arthritis, ELEVATED FERRITIN, multisystem invovlement HSM Labs: elev ferritin, leukocytosis, RF/ANA neg, anemia, thrombocytosis, abn LFTs Not lymphomas as BM bx neg Parvovirus B19 - arthritis and rash - days to weeks, after flu like illness SLE - not with elev ferritin, spikig fevers, salmon colored rash

Answer 242

Q1yr EGD Bx: intestinal metaplasia and goblet cells (no dysplasia) If low or high grade dysplasia -> esophagectomy BE-> inc'd r/o adenoCA COX-2 inhib not proven Endoscopic ablation on NON-dysplastic BE not recommended - Surgical fundoplication - pt with reflux sx refractory to medical tx - not shown to decrease cancer risk in BE

Answer 243

Dyslipidemia and Smoking greatest risk of MI | HLD, tob, psychsocial stress, DM, HTN, obsesity, etoh, physical inactiveity, diet low in fruits/veggies

Answer 244

Always feed enterally if possible well tolerated, low complication rate 25kcal/kg/day 2g/kg/day protein - combat adverse effects of malnutritio paraenteral nutrtion s/e infection, not superior to enteral Immunonutrtion not proven Lipid supplement not good

Answer 245

4mm aneursym too small to cause h/a | low risk = t intervene on small aneursym - risk higher of procedure

Answer 246

Pt with no fhx or personal hx of bleeding PT normal PTT prolonged, corrects ONLY PARTIALLY with mixing study - aquired hemophilia or aquired inhibitor to F VIII rare, life threatening Bleeding mucocutaeous and multifocal (echymosses etc) - no hemarthrosis Liver failure - defect in synthesis of all clotting factors - PT and PTT prolonged - except F VIII (prodxn in endothelial cells) - factor VII worse with shortest half life Plts also decreased Mixing study for PTT will correct completely inc'd fibrinolysis Factor XI - no prolonged mixing study - ashkanazi jews lupus inibitor - NOT CORRECTED in mixing study - actually cause VTE and arterial thombosis NOT bleeding

Answer 247

Varicella and other live virus vaccines contraindicated yellow fever, intranasal influenza, MMR, bCG, oral typhoid IBD patients immunosuppressed if protein def, getting high dose steroids (20mg/day), 6mp, azathr, MTX, TNF alpha, natalizumab - should get before immunosupp Should get HBV vacc, HPV, pneumococcal, regular flu shot (inactivated)

Answer 248

Mild hyperCa in young man with fhx of kidney stones and father with anesthesia induced HTN crisis Neck mass likely medullary thyroid CA Diarrhea from high serum Calcitonin from medullary thyroid CA Undx Pheo - explains fathers HTN crisis during anesthesia Brothers kidney stones from hyper PTH RET-protooncogene

Answer 249

inactivation of Ca sensing rct - higher Ca levels required to suppress PTH - PTH normal or slightly elevated - no thyroid mass or pheo

Answer 250

hyperCa from prodxn of 1,25 OHD3 from granulomas - would have abn CXR (hilar LAD)

Answer 251

Tx: immediate surgery 1 week of bloody diarrhea unresponsive to medical tx tachycardia, fever, hypotension, dec'd bowel snds, abd distenstion, transverse colon dilation on xray, If stable, medical therapy can be tried - IV steroids, abx, fluids, bowel rest CT scan inappropriate - needs surgery Infliximab good for flares for UC but not toxic megacolon IV steroids only for flares or stable toxic megacolon

Answer 252

Hydroxychlorquine - Preg cat C reduces lupus flares protection against organ damage, thombsos, bone loss continued indefinetly Pregnancy outcomes with SLE better in absense of active dz Azathroprine cat D but ok for severe SLE during preg if dependent on steroids Mycophenolate Moetif NOT DURING PREGNANCY Prednisone if symptoms worsen

Answer 253

Low dose ASA Preeclampsia = BP >140/90, >300mg proteinuria AFTER 20th week Sx: h/a, visual disturbance, liver dysfxn, fetal growth restriction, Methydopa - dec's bp but does not decrease r/o preeclampisa Ca supp - only reduces risk if low Ca diet to begin with Mg does not dec r/o eclampsia Don't need to keep bp <120/80

Answer 254

Statin will reduce risk most! Post menopausal, asx, overweight woman pt with DM - LDL goal t reduce risk either in this setting

Answer 255

Check peripheral smear r/o TTP - look for schistocytes microvascular aggregation of plts in brain and other organs (slurred speech, elev Cr, inc'd LDH Pentad - Microangiopathic hemolyitic anemia, neuro defects, kidney impairment, fever, thrombocytopenia tx: plasma exchange Only bmbx if pt thought to have primary marrow failure in setting of throbocytopenia - pancytopenia/abn lymphocytes on smear E coli O157:h7 - HUS but won't change need for plasma exchange No need for brain MRI

Answer 256

Tx: Hydroxychloroquine utricarial plaques fixed in location x 24hr cutaneous small vessel vasculitis likely underlying SLE with inc'd ANA and dec'd complement Use least toxic drug - hydroxychlorquine Methotrexate only if unresponsive to hydroxych or low dose steroids Mycophenolate Moetifil - steroid sparing agent for steroid dependent cutanous lesions not responding to MTX, hyroxCh, dapsone Cyclophosphomaide - severe refractory cutaneous vasculitis not responding to less toxic drugs

Answer 257

Rhine test - if bone conduction > air conduction - CONDUCTIVE HEARING LOSS Webber test - pitchfork on forehead - if louder in affected ear then CONDUCTIVE hearing loss -if louder in unaffected ear - sensoneural hearing loss MRI to exclude acoustic neuroma/meningioma if not clearly 2/2 to menieres dz Meniere's dz - low pitched tinnitis Behavioral therapy if underlying d/o w/u neg Sudden hearing loss - immediate tx with corticosteroids - BPPV - vestibular dizziness - otilith debris in semicircular canals - otolisth repositioning tx for BPPV

Answer 258

Worsening of MS sx can be brought on by UTI or metabolic derangement Pseudorelapse - tx UTI with 7 days of cipro (urinary sx, fever, dipstick +) - likely due to urinary retention Spasticity of legs and urinary sx Supportive care also - ie antipyretic for URI - should give neuro sx improvement 3 day course of methylpredisolone - distinct MS relapse - don't give with obvious UTI - could worsen situation Don't dec baclofen - could worsen spasiticity and not address urinary retention/UTI sx Inc'ing oxybutynin - worsens urinary retention and hence UTI

Answer 259

Cl ft - nephrotic syndrome, hematuria, HTN, kidney failure, throboembolic events - Risk factors for progressive CKD - older age, elev Cr dec'd GFR, male, HTN, secondary glomerulosclerosis, chronic tubulointerstitial changes - persistent proteinuria >4g/24hrs x 6 months, and decline of GFR = progression to advanced CKD Tx: ACEi & statin 2/3 pts -> remission, 1/3-> progressive CKD Avoid more toxic meds as 2/3 pts go onto spontaneous remission - initially avoid immunosupp meds (steroids, cyclophosphamdi, mycophenolate moetifil)

Answer 260

Tx failure - pt now with detectable VL when had previously undetectable viral load on same meds Continue current meds and perform viral resistance testing - start new meds once testing completed Don't just continue current regiment without resistance testing - could lead to future resistance - don't discontinue meds - partial suppression better than none (also selective pressure with meds onboard make resistence testing better - more resistant bugs when non-resistent bugs are suppressed) Don't just d/c drugs and test CD4 in 4 weeks

Answer 261

First step: ask pt and family about driving difficulties recent near misses, getting lost etc Risk factors for MVA - Age, visual deficit, dec'd motor fxn, dec'd cognifitve fxn, Premature to ask to stop drivign - before assessing driving skills - refer to driving rehab, provide pt with info on safe driving Local driving may be worse as more signs and confusion and congestion Report to state only if seizures or immediate threats - need to evaluate pt first

Answer 262

single dose IM benzathine PCN G has neg syphillis result 6 months ago but now + should screen HIV pt's regularly Partners should be evaluated and also be treated (regardless of serologic results) If any doubt they will f/u serologic testing should just treat before dx established Late-latent syphillis (>1 year or unknown duration) - 3 doses weekly IM benzathine PCN G Neurosyphillis - Aqueous crystalline IV PCN G CSF RPR >1:32, CD4< 350 - need to have CNS sx Doxycycline to tx syphillis if PCN allergic!!

Answer 263

Mild persistent asthma - >2 days/week (not daily) wakes up with sx 1 night/week (not nightly) Tx: add low dose inhaled corticosteroid (alt: leukotriene rct agonits or theophylline) Do not add long acting B2 agonist if not already on inhaled corticosteriod Only add long acting B2 if medium ICS doesn't work (don't add B2 and ICS at same time) Allergic immunotherapy not for asthma - just for allergic rhinitis

Answer 264

Pt with h/o pulm sarcoid now with adrenal insuff, hypothyroid, and hypogonadism - (low TSH and low free t4, low FSH/LH, low ACTH despite low morning cortisol and cortisol increases with cosyntropin stim test so adrenals ok) Polyuria and hypernatremia - central DI Needs pituitary MRI likely involvement of pituitary adn hypothalmic stalk by sarcoid, pituitary adenoma or sellar/parasellar mass No adrenal CT as likely central adrenal insufficiency No lung bx - No thryoid scan as pt has central hypothyroid

Answer 265

Pt is too sick for AAA repair no matter what dx testing would find Elective repair of AAA >5.5cm indicated for patients who are good opeartive candidates Not candidate for open repair - too many risks associated with endovascular repair post op for this patient No reason for Abd US, MRI or CT (they are good modality for dx) but findings won't change fact that this pt is not good candidate for repair.

Answer 266

Start Alendronate Female with osteopenia and high FRAX score (fhx mother hip fx and slim body habitus) - bisphonsponates for >20% fx in 10 years or >3% hip fx in 10 years and added that aromatase inhibitor will further decrease bone mass Denosumab - monoclonal ab inhibits osteoclast formation - for pts with high risk of fx and multiple risk factors or prev fx's No estrogen in pt with dx of breast CA Teriparatide - recombinent human parathyroid hormone - anabolic agent inc's bone density and dec's fracture risk but black box warning for osteosarcoma - contraindicaated if pt had radiadtion therapy which also in'cd osteosarcoma risk Raloxifene - selective estrogen modulator - osteoporosis prevention - by FDA - vasomotor sx - associated with use so not tolerated in pt with hot flushes arleady

Answer 267

Freshwater or saltwater mycobacterium local innoculation boating, handling fish, other marine activities granulomatous skin lesion If untreated can locally extend to joint nodular papules may form and ulcerate Dx: culture joint fluid for mycobacterial infxn Naeglleria foweleri - freshwater amoeba - freshwater lakes or underchlorinated pools - nasal exposure contraction - no joint infection but does cause nearly universally FATAL meningioencephalitis Neiserria gonnorhea - sexual activity - not local presentation in skin break and marine exposure no local arthrtis Sporothrix schenckii - soil fungus - enter skin thru breaks -granulomatous papular skin infection - spread lymphatically to joint - should have soil exposure

Answer 268

Mild parkinsoniansm with prominent bizarre visual hallucinations (tiger and bears in backyard), dream enactement behavior, atremulous parkinsonianism Pt recognizes halluncinations as NOT real but is still disturbing Tx of parkinsonian sx will likely exacerbate hallucinations Dopamine agonists CONTRAINDICTED Tx: levodopa when sx treatment needed Alzheimer's dz - comorbid with demtia with lewy body - no parkinsonianism or dream enactment beh or bizarre hallucinations Frontotemporal dementia - apathy, perservation, hoarding, disinhibition, personality changes Neurosyphillis - no rapid eye movement beh d/o - can cause dementia

Answer 269

Lifestyle modification + recheck BP in 1 year high risk to -> HTN inc'd age and fhx - inc'd r/o -> HTN given borderline BMI and lipids - lifestyle mods needed Ambulatory BP - suspect whitecoat HTN, monitor difficult to control HTN, or pt with hypotention on therapy - or autonomic dysfxn CRP - marker of inflammation - inc'd aw CV events - used to stratify pts with CV risk No need to tx pre-HTN with meds

Answer 270

``` 45XO short stature, shield chest, webbed neck Primary amenorrhea Bicuspid aortic valve (ejection click, early systolic murmur) aortic coarct, ascending aortic dilation inc'd r/o rupture 2.5cm2/m2 or greater ```

Answer 271

atrioventricular septal defect (partial or complete) | cognitive impairment, upslanting palebral fissures, epicanthal folds, open mouth protruding tongue, short neck

Answer 272

developmental d/o of heart and upper limbs Autosomal dominant 40% sporadic minor thumb abn to congiential UE defect osteoum secundum ASD most common cardiac defect

Answer 273

d/o of connective tissue tall stature, arm span > height, long fingers, joint hypermobility, sternal deformity, dilation of proximal ascending aorta, with or w/o MVP

Answer 274

typically follow acute pancreatitis and resolve on own - no dx testing needed EUS only for pancreastic cysts - mucinous cyst - check for septation, echogenic mucin or mass MRCP not needed because CT already showed no connection between pseduosyst and pancreastic duct percut/surgical drainiage not needed - pt asx - if becomes sx or fever, pain, anorexia then drain

Answer 275

Pt's younger than 65 with risk factors chornic CV dz, HTN, chronic pulm dz (asthma), chonric liver dz, , DM, etoh abuse, smokers - ok for pts with mild illness (ok in hopsitalized pts) - core measures for PNA pts Hep B - high risk pts for aquisition - travelocrs to endemic regions, sexual percutaneous risk (MSM, IVDA, health care workers) HPV males 11-21, 22-26 ok) - genital warts, anal CA, transmission of HPV to women Meningiococcal - adolescent living in dorms, miliary barracks or who are asplenic

Answer 276

TB (granulomatous dz) produces 1,25 OH Vit D3 (also sarcoid, crohns, leprosy) - macrophages in granumomas convert 25->1,25 vit D Will see low PTH in response (appropriate) Dehydration won't cause low PTH, just incd Ca Parathyroid adenoma would have inc'd PTH Humoral hypercalcemia - PTHrP - osteoclast activation, resorbtion of Ca in renal tubules, in'cd clearance of phos - usually when inc'd tumor burden

Answer 277

arterial hypoxemia - from pulm vasc dilation in seetting of portal HTN - aw cirrhossi - PO2 < 70mmHg, dyspnea Dx: saline bubble TTE - see microbubbles in LA within 3-6 cardiac cycles - indicated dilated pulm vasc bed Tx: Liver tx Deconditioning does not cause hypoxiemia Myocardial blood flow not affected by HPS Portopulm HTN - PAH in pt with portal HTN-not aw arterial hypoxemia -

Answer 278

Asx pt with blasto in stool - no need for further tx no additional stool cultures to document clearance -protozoal parasites frequently found in human stool - no diff in pts with or w/o diarrhea Cipro no activitiy against blasto Bactrim and flagyl ok Sx tx for 48-72 hrs - immediate studies for pt immunocomp, severe sx, comorbidiies public contact (food preparers/childcare workers)

Answer 279

inc'd r/o kidney stones - in'cd r/o cal phos/caoxalate stones

Answer 280

Dypnea, chronic cough, sputum prodxm, smoking hx FEV1/FVC check bronchial challenge testing - uses broncoconstriction inducing chemicals CT only if suspicion of lung CA - won't dx COPD DLCO - >80%= normal - presence of parenchymal dz and pulm vasc dz - normla in pts with abn spirometry and lung volume measures

Answer 281

Needs antepartum AND post partum ppx 6 weeks LMWH NO WARFARIN - embryopathy LMWH/UF AND ASA only in pt's with antiphospholipid syndrome and recurrent fetal loss Can't do with NO ppx

Answer 282

reported memory loss, some impaired fxn, no other cognitive inovlvment MMSE ~ 26 No problem with executive fxn, language diff, ADL, Tx: Cognitive rehab - neuropscyh = ext memory aids and organiz/attention skills - some improvement in fxn Alzhemiers - use anticholinesterase inhib - donezepil, galantimine, rivastigmeine - modest improv ADL, fxn (does not slow MCI -> dementia) No role for PET Pt with MCI to -> dementia at rate of 12%/yr

Answer 283

Medical therapy for HR and BP only No need for urgent surgical or endovascular repair Equal flow (equal contrast) in main lumen and dissection flap Cocaine use aw aortic dissection Medical tx - 90% 30 day survival HR<60, SBP 100-120 - reduce aortic shear stress in setting of cocaine use - use labetolol (both alpha and beta blockade) If life treatening organ ischemia (ie renal, mesenteric, peripheral ischemia) then emergency fenestration of flap needed PPX stenting of false lumen not better than medical therapy for type B dissection Surgery or endovasc stenting for pain despite med tx, threatened aortic rupture, malperfusion syndrome

Answer 284

Repeat BP measurement when one erroneous reading by staff - errors in position, cuff size, talkign, recent caffeine or nicotine 5 minutes rest, empty bladder, back supported, feet on floor, proper cuff size, cuff bladder 80% arm, on skin (not thru clothes) Adjust meds only if repeated measurement has inc'd BP Ambulatory BP monitoring if suspect Whitecoat HTN, masked HTN to see if BP ok outside office or hospital setting

Answer 285

Acute mountain sickenss/periodic breathing - when gradual ascent not possible - use acetazolamide h/a, nausea, sleep disturbance (high altitude periodic breathing - altitude associated breathing change), fatigue, Best tx: gradual ascent Next best : acetazolamide 24-48 hrs prior Accelerate acclimitazation by stabilizing ventillation, improve oxygenation, counteract fluid retention by mild metabolic acidosis Also give to pts with cardiopulm dz Dexamethasone - for established acute mountain sickness or cerebral edema Effect of acetazolamide in decreasing HAPB not thru diuresis - furosemide won't work Zopidem won't work for HAPB

Answer 286

Aspergillis MC fungal infection after tx (esp lung tx or neutropenic phase after hematopoetic stem cell tx) Fever, dry cough, hemoptysis Dissem to brain - h/a focal neuro def, MS change Risk factor: neutropenia, persistent fever while on broad spec abx, pulm nodules Tx: Voraconazole (Fluconazole covers for candida NOT aspirgillis) CMV PNA - less likely in first few weeks (can occur weeks to months out ie POST ENGRAFTEMENT phase) - also NO pulm nodules Murcomycosis (zygomycosis) - rapidly progressive fungal infxn in pt with heme malignanies - or other d/o with prolongued neutropenia and immunsupp (severe burns, trauma, DKA) - inc'd risk with corticosteroids, cytotoxic agents, deferoximine Rhinocerebral/pulm inovlvment - most common -less likely to be early fungal infxn following stem cell tx PCP PNA - less likely in acute setting followign tx - chest xray b/l infiltrates - but can vary from normal to nodules, pleural eff, cysts, consolidations

Answer 287

Cause of Pure Red Cell Aplasia absense of erythroid precursors in marrow, severe anemia, lack of retics, Leukocyte and plt prodxn UNAFFECTED Smear with large granular lymphocyte - abundant cytopalsm with azurophillic granules CD57+ Tcells and clonality on T cell rct gene rearrangement studies MDS - ineffective hematopoesis with pancytopenia and hypercellular marrow with dyerythropoesis Parvovirus B19 = viral syndrome, malaizse, fever, arthraliga, - no splenomegaly - BM shows giant pronormoblasts - no large granular lymphocytes on smear Thymoma - paraneoplastic effects - Myasthenia gravis, PRCA, hypogammaglobulinemia Teratomas

Answer 288

OA dx clinically...no advanced imaging needed Pain + 3 of following age>50 stiffness t help

Answer 289

+fhx, +thyroid peroxidase Ab, small goiter, desire to become pregnant Subclinical hypothyroid - elevated TSH with T4 and T3 in reference range Mild or no sx of hypothyroid Tx for pt with TSH >10 Tx: lower threshold for pt with goiter, fhx thyroid dz, antiTPO ab or pregnant Need to avoid hypothyroid during preg because cuases low birth wieght, inc'd r/o miscarriage, premature death, fetal loss, Optimal TSH in preg 0.5-2.5 FNA only for thyroid nodule NO reason to wait 6 weeks and check TSH again Thyroid scan only if nodule or painful gland + unecessary radiation risk

Answer 290

Probenecid increases urate excretion - good in pt that is underextreter (low urine urate despite hyperuremia) does also inc r/o kidney stones so need urine alkalyzation and aggressive hydration - use with caution in pt with r/o stones (ie h/o tophaceous gout or stones) Azathroprine active metabolite broken down by XO - so DO NOT USE XO inhibitor or get azathroprine tox (ie allopurinol, Febuxistat) Pegloticase - immunogenic - lowers serum urate by enzymatic digetstion - only approved for tx failure gout

Answer 291

FIRST check CD4 ct needs vaccin against Hep B, varicella, MMR, dipthera, pertussis, flu vaccine No live vaccines in immunosupp pts or HIV pt CD4200 Only inactivated flu shot Hep B for HC workers, HIV pts and unknown hep B status - first get CD4 ct Pt born after 1980, HC workers with and those borne before 1980 with high risk for varicella should get varicella vaccine - unles seroligc evidence or physician documented evidence of varicella or varicella vacc - PT SELF REPORT NOT GOOD ENOUGH

Answer 292

``` CJD (sCJD) - accumulation of prion protein in neural tissue - spongiform brain pathology relenteless sx progression progressive dementia myoclonus bland CSF findings non-dx imaging of brian Dx: need path of brain (spongiform changes EEG: 1-2 Hz periodic sharp waves CSF: 14-3-3 protein ``` Cryptococcal and mycobacterium inf of CNS - subacute to chronic meningitis CSF: pleocytosis h/a, fever, meningeal signs NO MYOCLONUS Tertiary neurosyphillis - dementia is possible - months to years - CSF pleocytosis

Answer 293

Abd pain after eating (30 min) -> weight loss ie intestinal angina fear of eating 2/2 pain (contrast to acute mesesnteric ischemia - sudden onset) Progressive - mild pain while eating, food intolerance then pain without eating Risk: age, HTN, HLD, smokign Dx: doppler (low sens) - MRI/CT angio Tx: PTCA - definitive=surgical revascularization

Answer 294

pain, malaborption, new onset DM - chornic constant pain in midepigatrum -> back, exacerbated by food

Answer 295

reversible colonopathy, stricure, gangrene, , chronic colitis acute onset LLQ pain - urgent defication - red or marron rectal bleeding

Answer 296

nausea, vomiting, bloating, postprandial fullness, early satiety, abd discomfort, succession splash

Answer 297

Cladribine - single cycle curative in 80% sx: fatigue, abd distention, enlarged spleen, no LAD Pancytopenia BM aspirate - "dry" tap BM bx - diffuse infiltration - small lyphocytes hairlike projections Don't observe, treat - no further imaging (PET or CT) needed

Answer 298

flu like sx prodrome (crop dusters? - handling infected animals, wools, hides) rapid septic state (hypotension, tachy, skin cool/mottled, diminshed breath sounds b/l) CXR: widened medistinum (spores lead to tissue destruction and hemorrhage in mediastinal LN and cause diffuse LAD) Spores lie dormant in soil - can be infected thru cutaneous, ingestion or inhalation (doesn't spread person to person) Tx: Cipro, doxy, PCN

Answer 299

gram + bacillus - occupational contaminated meat/fish usually cutaneous infection

Answer 300

ingestionc ontaminated food/unpaturized milk - severe dz in elderly and immunocomp - usually diarrheal illness

Answer 301

cutaneous, lymphocutaneous, pulmonary, or central nervous system dz - nodular/cavitary lung lesinos

Answer 302

Gallbladder inflammation in absense of obstructive cholelithiasis Abd US - demonstrates GB wall thickening/distention Chronic stasis of bile in GB from underlying dz 10% acute cholecystitis Sx: upper quad pain, fever, leukocytosis, abn liver enzymes - Dx: US - gall bladder wall thickenss, sludge, hydrops Tx: cholecystectomy EUS with bx would no give explanation for elev liver enzyes, distended gallbladder and fever If no suspicion of AAC - MRI MRCP would be reaonaable to r/o biliary tract path - choledocolithiasis, biliary stricture, extrinsic Liver bx if MRI MRCP neg and still abn liver enzymes

Answer 303

Pt with atypical CP but age and sex makes him intermediate risk Pt has normal EKG and is able to walk so Excercise treadmill stress test is best to start Pharm nuc - only if pt can't excercise 2/2 arthritis, deconditioning or advanced lung dz and in setting of abn EKG Cath - only if pt has limiting angina despite OMT, high risk stress test result or sucessful resucitation from SCD TTE - does not exclude underlying CAD (normal echo) - can assess LV fxn, valve abn, WMA

Answer 304

ASA, BB, statin h/o CAD - ASA, BB elevated LDL - statin goal < 100 (CAD+DM t go without therapy - needs all 3

Answer 305

Predicts in flight hypoxia in COPD patients PO2 < 70= indication for HAST In flight O2 needed if during HAST PO2 < 50 if >55 no O2 needed 50-55 borderline - need stress HAST EST, 6 min walk test, PFT do not predict in flight hypoxemia

Answer 306

MC anterior pitutiary problem after Traumatic brain injury is GH deficiency Change in body composition - inc'd central adiposity, reduction musle mass, dec'd bone density, dec'd libido Dx: IGF-1 Do no just test GH - pulsatile hormone Glucose tolerance test is for GH excess and suppressibility when suspecting acromegaly Gonadotropin releasing hormone - don't need if pt has high testosterone

Answer 307

``` Need early agressive rehab after stroke - pt at risk for DVT Speech/swallow therapists tx post stroke depression No ppx abx even if swallowing issues No role for carotid stenting ```

Answer 308

Use CT with contrast (ok in pt with minimal kidney fxn on HD) Only avoid nephortoxic agents in pt with significant kidney fxn residual Intravenous pylography outllines collecting system - can't tell malignant from benign masses Don't use MRI with GAD - nephrogenic systemic fibrosis (NSF) - edema, thickened skin - affects visceral organs No PET for kidney masses - kidney has high baseline activity so PET useless

Answer 309

Temporal arteritis Tx: immediate prednsione tx -> temporal artery bx Sx: elderly global non-descript h/a, progressively worse, maliase, fatigue, tenderness in scalp over temporal areas, elev ESR, CRP No need for HCT or cerebral angio if doesn't suggest stroke, aneurysm, CV occlusion No LP if meningitis not suspected

Answer 310

``` emergent delivery of fetus RUQ pain, elevated liver enzymes, low plts, hemolysis (schisotcytes on smear) High AST/ALT Pre-eclampsia - HTN/proteinuria/edem (3rd trimester) (DDX - TTP, DIC, HUS) ``` No corticosteroids, IVIG Plasma exhange only if sx persist after delivery

Answer 311

No bronchial challenge testing during pregnancy - methacholine/mannitol cat C - can't use Just add long acting B2 agonist if not sufficent control with as needed B2 agonist (short) and ICS Theophylline not preferrred in preg patients

Answer 312

``` abrupt onset of eye pain and redness photophobia, tearing, dec'd vision, h/a urgent opthal eval Systemic dz associate - sarcoid, behcets, spondyloarthrtis, granulomatosis with polyangiitis (wegeners) Dx: check CXR r/o sarcoid HLA B27 - r/o spondlyoarthritis ANCA - granulomatosis with polyangiitis RPR - r/o syphillis ``` Posterior uveitis - sarcoid, TB, histo, syphillis, lyme Anti DSDNA - SLE (retinal vasculitis) Anti Ro/SSA - Sjogrens - dry eyes, corneal ulceration RF - dry eyes, episcleritis, scleritis

Answer 313

necrotizing vasculitis of medium sized vessels aw HEP B!! angiogram - aneurysm/stenosis of med vessels (renals) ANCA NEG fever, abd pain, arthralgia, , mononeuritis multiplex, ulcers, purpura, livido reticularis Dx: skin/sural nerve or angiogram Giant cell arteritis - large/med vessels of head/neck - temporal, opthalmic, ciilary - no kidney inovlvmenet Granulomatosis with polyangiitis - necrotizing vasculitis - kidney and resp tract - p/w upper airway sx - sinusitis - kidney bx - pauci immune crescentic glomerulonephritis - no aneursyms Takayasu arteritis- chornic vasculitis of AORTA and major branches inflammatory dilation/stenosis of major aortic vessels h/a vertigo, visual impairment, renovascular HTN Age 10mm in UE

Answer 314

Contact hospital admin and report right away for patient saftey sake (do not wait till monday, could harm patients until then)

Answer 315

``` No splenomegaly, normal peripheral smear Sx: none or mild to severe bleeding in setting of normal CBC - Can be drug induced If Plt>30-40 -> low risk Repeat CBC in 1 week ``` If < 30-40 or with bleeding -steroids/eltrombopag No need for BM bx if peripheral smear normal except for thrombocytopenia Do not check anti-plt Ab - lots of false +/ false -

Answer 316

``` abrupt cervical pain + horners syndrome +h/a (ipsilateral neck, face, orbit) horners, amaroxix fugax, retinal infarction, pulsatile tinitis, diplopia, stroke sx Etio - traumatic - chiropractic Dx: Imaging (angio/CT/MRA) ``` Not migraine if secondary h/a suspected isolated horners unliekly in stroke Cervical herniation not likely to produce horners

Answer 317

Statin now type 2 DM - poorly controlled LFTs mod elevated but no other evidence of liver dz so ok to start statin even with mildly elev LFTs (3x ULN) Fibrates don't reduce LDL much Don't wait to start statin until glycemic control or LFTs normalize Don't use nicotinic acid first - can raise glucose/LFTs, can cause liver damage - adverse s/e

Answer 318

Stroke unit admission - reduces mortality beneficial 2/2 interdisciplinary care, emphasis on early rehab No rehab yet - needs hemodynamic stability, etio of stroke determined (CV/vasc imaging) No reason for ICU - BP does not need acute lowering

Answer 319

Surgical AVR decompensated HF 2/2 severe AS despite LV dysfxn has good gradients across stenostic valve - needs AVR No BAV - only for pt with severe AS and hemodynamic compromise - as bridge to eventual AVR - if HD stable with diuresis then no need - high rate of restensosi w/in 6 months No TAVI - only in pt with high predicted surgical mortality No nitroprusside - only with severe AS c/b decompensated HF and low CO - not if responds to diuresis

Answer 320

with CO poisoning and high carboxyHg levels tx: 100% O2 and HYPERBARIC oxygen tx to prevent delayed neurocognitive impairment (hyperbaric does clear faster but 100% O2 clears very well too if hyperbaric not available) Mechanical vent not needed if resp failure not immienet, (or if evidence of airway thermal injury or low solubility toxin) Pulse ox UNRELIABLE with CO poisoning/carboxyhG falsely reassuring o2 sat- need to follow ABGs or CO-OXIMETRY - monitor oxyhemoglobin levels

Answer 321

lactate level >90 specific for cyanide poisoning | tx: sodium thiosulfate

Answer 322

Two newly enlarged supraclavicular LN - pt with SLE on immunosupressives with inc'd r/o Malignancy (NHL, HL, lung Ca, hepatobiliary CA, cervical dysplasia) Bx LN Increasing immunsupp won't tx or dx new LAD Don't need to test for TB in setting of new LN - need to bx r/o malignancy - TB skin test likely neg in setting of immunosupp anyway - LN bx will show TB if present

Answer 323

Pulm nodule < 4mm in smoker/former smoker - f/u CT 12 months - if nodule unchanged - no further imaging needed Non-smoker - <4mm nodule (with no 1st deg relative lung Ca, or radon/asbesetos exp) NO F/U imaging needed 4mm or larger - follow guidelines New nodule 8mm or larger with no old imaging - prompt calc and prob for malignnacy - consideration of additional imaging or bx Solid nodule - stable on cxr or CT x 2 years is considered benign - growth is strong indicator of malignancy

Answer 324

Helical non-contrast CT (gold standard) Stone hunt CT New onset gradual abd/flank pain - urinalysis with hematuria and low grade pyuria - aw kidney stones KUB can detect most radioopaque stones - false neg with small stones, uric acid stones, indinavir related stones, interfernce of overlying bowel (use to follow burden) MRI can't visualize stones Intravenous pyelography very spec and sens but requires use of contast (contraindicated with aki) Kidney US no radiation but lower sens/spec - may require confirmatory CT anyway

Answer 325

Measurement of CRP can reclassify intermediate risk (framingham 10-20%) pt to either low or high risk + ASA and crestor to meds CRP >0.2 with LDL < 130 - benefit from crestor + ASA No benefit from B carotein, vitamin E, folic acid, vitamin C

Answer 326

Perform HSV PCR pt with HSV-2 genital - may have prodrome of prurutis but no gential lesions Presense of fissure can be atypical HSV-2 presentation (can also do viral culture - less sensitive) Lymphogranulum vernerum - genital ulcer dz - L1,2,3 serovars of chlymdia Painless papule or ulcer at site of innoculation, resolves without tx - > followed by PAINFUL unilateral inguinal LAD - with fever/malaise Tzanck smear for HSV LOW SENSITIVITY - don't use Candidal vulvovaginitis - have vaginal pruritis/burning/fissures - but ALSO HAVE VAGINAL D/C - so if no vaginal d/c then no KOH mount needed

Answer 327

Supportive care and diuretics/antiHTN for fluid retention and HTN Immunologic dz triggered by infection - > release of immunoglobulins and activation of complement proteins (low complement) - depostited in glomeruli - activating cytokine pathways Acute nephritic syndrome - rapid onset of edema, HTN, oliguria with low urine Na+, erythrocyte casts in urine Do not require kidney bx for dx Bx only if course or findings are atypical for PSGN or if no clear antecedent streptococcal infection Early tx of infection can lessen severity of PSGN Managment of PSGN is supportive only (extreme - HD if needed - otherwise diruesis and anti HTN agents) Less common - PSGN can manifest as Rapidly progressive glomerulonephritis - advanced kidney dz Tx: intravneous pulse methyprednisolone, prednisone, cyclophosphamide, cyclosporin or plasmapheresis - if early in course - condition could likely resolve on own with supportive care needed only

Answer 328

After bx confirmed dx of esophageal adenoCA need STAGING with CT/PET and endoscopic US SCC in upper esophagus AdenoCA in lower esophagus Sx: dysphagia for solid foods Odynophagia is less common (aw ulceration of lesion) other sx - CP, anorexia, wt loss, GIB, regurgitation Endsoscopic bx - dx tumor CT/PET - detect distant mets EUS - tumor and LN staging May also need VATS In pt with mediastinal regional LAD - neoadjuvant chemoradiotx followed by surgery better surviival No need for feeding tube if no wt loss or inability to sustain caloric intake Loss of >10% body weight, evidence of malnutrtiion on exam or labs, inability to maintain caloric intake -> indication for feeding tube or perc gastostomy tube Radiation tx - pt with localized CA and not good surgical candidate - or pt with clearly unresectable CA - or palliative care for pt with severe pain due to mets not controled with pain meds

Answer 329

LFTs < 3x ULN ok or total bili >2x ULN Measure LFTs prior to therapy and clinically after if evidence of liver dysfxn (clinically) LFTs usually rise in first 12 weeks after starting statin therapy, are asx and resolve without d/c'ing statin (thought to be 2/2 leak of liver enzymes 2/2 inc'd hepatocytes permeability) - no associated hispatholic changes - most common with higher doses of statins Statin only to be d/c'd if clinical evidence of hepatoxcity - usually only occurs in setting of underlying liver conditions or drug interaction (ie taking tylenol as well) In setting of hepatoxiticty - persistent elev after d/c'ing statin - warrants further w/u with liver US Common causes of liver dz should be r/o HEP C, Non etoh fatty liver dz, autoimmune hepatitis (ANA, SMA, Mitox) Check serum Ab and liver US - withold statins till investigation complete

Answer 330

Tx: close observation, palliative care as needed chronic myeloprolif d/o characterized by overprodxn of megakaryocytes and bm stromal cell mediated collagen depostion - JAK2 Peripheral smear : leukoerythroblastic findings - tear drop shaped cells and megathrobmocytes Bone marrow aspirate "dry" - unsuccessful aspirate BM bx - marked fibrosis Low risk: absence of: 10, leukocytes< 25, circulating blasts less than 1% Allogenic hematopoetic stem cell tx - potentially curative for PMF but significant mrobidity/mortality - only consider if progressive dz - Transplant preferred tx for younger pt with 2 or more adverse prognostic factors Danazol - tx PMF related anemia if Hg<10 or tranfusion dependent Hydroxyurea - if constitiution sx like fever, wt loss, night sweats, sx splenomegaly, problematic throbocytosis Imantimib - appropriate therapy in pt with with CML (not PMF) - pt neg for t(9,22) translocation

Answer 331

D/C etoh use prior to MTX inititiaion - can cause MTX induced hepatitis Also caution of MTX use in pt with pre-existing liver dz Want to continue folic acid - reduces MTX induced liver toxicity Continue hydroxychloroquine - synergistic and lowers r/o liver issues Steroids have good short term control so should be tapered to lowest effective dose NOT d/c'd with initiation of DMARD (MTX) No absolute indication to quit smoking with starting MTX but good for overall health

Answer 332

>4cm with LN involvement - tx with thyroidectomy/levothyroxin then radioactive iodine tx - decreses r/o recurrence and death - relapse in 12% of pts with no evidence of dz after primary resection Tumors not tx'able with surgery, levothyroxine and radio iodide therapy - are treated with ext beam radiotherapy or chemotherapy (cytotoxic drugs ie doxorubicin) - response is poor Observation not good - need radioiodide tx

Answer 333

Patient with normal EKG, echo, holter/event recorder and still with syncope needs TILT TABLE TESTING discriminates neurogenic vs orthostatic syncope and evaluate freuqent syncope in pt with psych dz (ie pt with no orthostasis) EEG - in pt where syncope thoguht to be cuased by seizure - if pt no risk factors or prodrome, seizure activity or post ictal state - not likely Excercise cardiac stress test - low yield for syncope pts at low risk for ischemic heart dz (normal echo, EKG) Signal average ECG - detect altered depolarization through myocardium that leads to re-entrant arrythmias - that may not be evident on regular ekg - ususally for pts after MI to assess for r/o VT - not used for evaluation of syncope

Answer 334

Pt with UC/Crohns with dz flare and inc'd diarrhea Check stool studies, O&P, c diff CAN HAVE CDIFF IN YOUNGER PT with NO PRIOR ABX USE in setting of inflammatory bowel dz Especially suspicious is high WBC (>20K) Tx: usually oral flagyl - however with inflamm bowel dz - can use oral vancomycin If no oral intake - IV flagyl or vanco enema - CT only if inc'ing abd pain, distention, rebound/tenderness, hypoactive bowel r/o toxic megacolon/perforation RUQ US only if si/sx of cholelithiasis Colonoscopy second linie if pt does not respond to c diff therapy, UC therapy or another infection therapy Consider superimposed CMV infection in pt on long standing steroids for inflamm bowel dz - obtain bx specimen from colonoscopy

Answer 335

D/C vanc and start DAPTOMYCIN (vancomycin intermediate Staph aureus - VISA) MIC >4mg/mL Dapto is alt to vanc for VISA - Don't use linezold for blood infection of VISA/MRSA Bactrim only for skin/soft tissue MRSA, not for blood infection Don't just increase dose of vancomycin when MIC high, won't work and will cause vanc toxicity

Answer 336

Long standing SLE - high risk for premature atherosclerosis and MI - need EKG stat for rapid dx and tx SLE death pattern Early: active dz and infection (immunosupp) Late: CV dz - develop sx at younger age - women 35-44 - 50x more likely to develop CAD Risk factors: DM, HTN, HLD - all worse with chronic steroids longer course=more risk n/v not typical sx of CAD - but not uncommon esp in F's CT angio of abd - for pt with abd symptoms - and postiive antiphospholipid Ab with unexplained abd sx - r/o mesenteric thrombosis and ishemia CT pulm angio - next step if EKG normal - r/o PE - may p/w CP, dypnea, tachycardia - pain pleuritic RUQ sono if suspect acute cholecystitsi - but unlikely without fever, RUQ tenderness

Answer 337

Continuous machine like murmur Below left clavicle envelops S2 No parasternal impulse, no pulm HTN, no pulse delays

Answer 338

continuous murmur - obstruction from coarct and collateral flow left infraclavicular region +systemic HTN +radial femoral pulse delay

Answer 339

fixed split S2 systolic murmur 2nd L ICS - inc'd flow thru pulm valve diastolic rumble if shunt large (not audible in left infraclavicular space)

Answer 340

``` systolic murmur 2nd L ICS INcreases with INspiration pulm ejection sound - dec's with inspriation no diastolic murmur unless PR as well ```

Answer 341

systolic murmur that envoelops S2 | No diastolic murmur unless concominent AR

Answer 342

``` Bone marrow fails to produce blood cells hypocellular BM and PANCYTOPENIA Bleeding(thrombocytopenia), fatigue(anemia), fever(neutropenia) Prodrome viral syndorme (EBV, CMV) Low retic ct, hypocellular marrow ```

Answer 343

malignancy of myeloid progenitor cells Age ~ 67yo presentation similar to aplastic anemia BM bx - abundance of myeloid cells (not hypocellular) (can tx from MDS - philadelopha chrom t(9,22)

Answer 344

``` MC form of lymphoid malignancy Dx age 70s - unusual in young patients Symptoms vary - may be asx at dx Leukocyte count ELEVATED at dx BM bx: prevalance of lymphocytes ```

Answer 345

``` clonal hematopoetic stem cell d/o ineffective hematopoesis Tx to AML Incidence INCREASES with age NOT usually acute or in young patients BM: hypercellular (not devoid of cellular elements) ```

Answer 346

Gastric carcinoid tumors noted on EGD for non-specific gastric sx as incidental findings Type I gastric carcinoid tumor: single or multifocal - 95% Tx: endoscopic removal of tumors + EGD surveillance q6-12 months for 3 years Octreotide tx - symptom control for flushing and diarrhea in pt with CARCINOID syndrome (particularyly type II tumors in zollinger ellison syndrome or MEN type 1) Octreotide inhibits hormone secretion from many tumors ie carcinoid, insulomas, gastrinomas - binds to somatostatin rct's Antrectomy - reduces G cell mass - lowers serum gastrin levels - thought to stimulate type I gastric carcinoid tumors - only for numerous tumors >5 or large tumors Total gastrectomy - Type III - sporadic gastric carcinoid tumors - aw normal gastrin levels - unfavorable prognosis - justifies aggressive surgical intervention

Answer 347

Acute onset flaccid paralysis Check West nile IgM ab assay Transmission from bird-> mosquito-> human Poliomyelitis like syndrome NM sx - mild unilateral wk to quadriplegia with resp failure Can overlap with encephalitis or meningitis Ab better as viremia is brief in duration so PCR is neg in 40% Ehrilicosis - febrile illnes with polyradiculopathy, occ meningioencephalitis but no focal paralysis ``` Borriella burgdorfi (lyme) - neuro sx occur >1month after infection Early dissemninated lyme - aseptic meningitis - cranial neuropathy, or radiculopathy - encephalopathy or encephalomyelitis also possible ``` CMV - polyradiculoapthy - but only in pt with advanced HIV - sensory loss and urinary retention

Answer 348

Flank pain with fever in pt with ADPKD Can be infected cysts no abn findings on u/a or u culture (don't communicate with rest of urinary tract) Tx: abx with good abx coverage for urinary tract bugs and good cyst penetration (cipro) - 2-4wks nitrofunatoin, cephalopsportin, PCN (amoxicillin) DO NOT PENETRATE CYSTS WELL Pt with ADPKD can also have cystic hemorrhage rupture - with flnak pain and low grade fever - however not likely if fever with elev WBC

Answer 349

Needs empiric abx - vanc + zosyn Has gout attack - presence of tophi + intra/extracell neg birefringent crystals (urate) Also with high WBC in synovial fluid >50K so ALSO SEPTIC JOINT NEG GRAM STAIN INSUFFICIENT TO R/O infection!!! Pt with chroic joint damage from frequent gout attacks and DM at higher risk for joint infection Surgical drainage/debridement only after infection confirmed on ctx - tx with abx first (surgery first only if definite infection and inadequately perc drained joint) Intraarticular steroids - for acute gout attack - whilte minimizing systemic steroid effects - but never inject into potentially infected joint Also prednisone ok for polyartiuclar gout but never until infection definetly ruled out

Answer 350

``` Normal office BP with high ambulatory BP Need ambulatory BP monitoring Likely explanation for unexplained LVH inc'd r/o CV events suspicious if office bp normal and home BP high or discovery of unexplained findings like LVH ``` Cardiac MR - if hypertrophic CM suspected with nondx TTE - MRI can detect focal areas of scarrign and ventricular hypertrophy - TTE findings of HOCM - asym hypertrophy of ventricle - preserved systolic fxn but has diastolic dysfxn Treat with BP meds if ambulatory BP monitoring shows high BP at home CAC - correlates with r/o CAD but not direct measure of severity of luminal CAD - not indicated for routine screening - can be considered for asx pt with intermedicate risk score for CAD - 10-20% - because CAC>400 indication for more aggressive preventative medical tx - won't explain LVH

Answer 351

Adenosine deaminase >70u/L -> tuberculous pleural effusion (0.6, fluid protein/serum protein>0.5) If ADA elevated - start TB therapy and get pleural bx If left untreated can resolve spontaneously but may return as active TB Negative pleural stain for acid fast bacilli DOES NOT R/O TB, pleural fluid cultures are also often negative even with active infection Gram stain likely won't establish dx Bacterial PNA with parapneumonic effusion likely not case in subacute presentation - usually have more cells in bacterial pna with parapneumonic effusion

Answer 352

Excercise EKG stress Despite higher false positive rate in women - use Excercise EKG stress first Needs stress - has risk factors - Fhx premature CAD, HTN, HLD Atypical - sharp, not exertional, localized, resting EKG normal - pretest probability intermediate Excercise EKG stress ok in pt with RBBB, less than 1mm ST dep at rest, provides prognostic indication based on excercise duration, presense or absense of angina, magnitude of ST changes (DUKE TREADMILL SCORE) No cath as pt pretest prob is intermediate (not high) Pharm stress not indicated - pt able to excercise - dob (inc's HR and contractility) or vasodilators (causes increases in relative bloodflow to myocardial regions not supplied by stenotic vessels) - exc provides additional dx info and prognostic info and is therefore preferred if possible) Do not use imaging (echo or perfusion) in absense of baseline ECG abn - even though increases sensitivity of EKG stress - does not reduce cardiovascular events

Answer 353

Glucocorticoid insufficiency 2 weeks after d/c'ing megastrol (has strong glucocorticoid activity) - suppresses hypothalamic pituitary adrenal axis - sudden discontinuation causes adrenal insufficency Megastrol - used in patietns wth anorexia as appetitie stimulant - Physical exam - plethoric rounded face, cervical fat pads, central obesity - cw exogenous glucoorticoid - also low ACTH despite low cortisol also TX: oral hydrocortisone No need for CT - is central adrenal insuff (inactivated axis) Dexamethaosone supp test - used to investigate hypercortisolism - Low dose DMS test - suppresses cortisol in pt with no pathology in cortisol production High dose DMS - suppresses overactive ACTH cells in pitutiary but not in ectopic ACTH producing cells or adrenal adenoma If ACTH low or undectable and cortisol not supperessed by high or low DMS then primary hypercortisolism likely If ACTH normal to elevated, cortisol not suppressed by high or low DMS then ectopic ACTH likely - if no adrenal tumor then need CT to r/o other tumor producing ACTH

Answer 354

Sx: h/a, recent DM, HTN, glove/shoe size increase, painful knee/hip - sleep apnea, carpel tunnel syndrome, coarse facial features, frontal bossing, acc nasolabial folds, large tongue Dx: check serum IGF-1 (high GH cuases liver to produce IGF-1) - DO NOT MEASURE GH - is pulsatile If unclear can use glucose tolerance test - GH levels not suppressable by hyperglycemia in acromegaly Prolactin not useful in dx acromegaly MRI can show pituiary adenoma but not dx of acromegaly - after dx can do MRI to determine etio of acromegaly and size/location of adenoma

Answer 355

Estrogen OCP can reduce levels of lamotrigene and other AEDs - need to increase dosage if starting OCPs or will lead to more seizures (reduces levels 40-60%) Check baseline drug level before OCP then check again 10 days after increasing AED and starting OCP Don't use low dose combined OCPs Don't use combined OCPs in pt taking carbamazepine, phenytoin, barbituates, pirmadone, topriamate, oxycarbazepine - inc meatabolims of OCP making useless would inc r/o unplanned pregnancy carbamazepine and phenytoin bad for pt with idiopathic generalized seizrues - may exacerbate Don't just keep AED at same level

Answer 356

EGD Pt with birds beak on barium swallow and and esophageal manometry showing aperistalsis Next step = EGD to eval esophagastric jnc Failure of lower esophageal junction to relax dysphagia, CP, regurg of food, wt loss (Deg of myenteric plexus) - leaves LES tonically contracted EGD to r/o malignant mass (direct malignant infiltration or paraneoplastic syndorme) Myotomy - 1st linie therapy after EGD confirms no mass at EGJ - CT abd/chest - if mass discovered on EGD at GE Jnc - maligancies aw pseudoachalasia are usually adneoCA - need CT for staging - if metastatic spread - no surgery Swallowed aerosolized steroids - eosinophillic esophagitis - young man with h/o asthma - food impaction, heartburn, dysphagia

Answer 357

Need to admit to hopsital even for small (2cm Needle decompression less effective than tube throacostomy If air leak >3-5 days - consider difineitve tx with pleuredesis - chemical or thorascopic

Answer 358

Pt pw meningioencephalitis - AMS >24hrs aw fever, seizures, pleocytosis (CSF), abn neuroimaging HSV MCC of meningioencephalitis (sporadic) threfore empiric therapy should be started If HSV PCR neg may d/c acyclovir tx for HSV Oral acyclovir/valcyclovir don't penetrate CSF well so do not use anyway Usually pt with HSV encephalitis have abn MRI - if abn then continue acyclovir until 2nd CSF sample 2-4 days later - If + HSV PCR then tx with IV acyclovir x 14-21 days

Answer 359

All adults need vaccination against influenza yearly regardless of risk factors Between Sept and March Healthy adults either inactivated IM or live attenuated intranasal vaccine HBV vaccine - all children and adults thru age 18, ppl with HIV or other recent sexually transmitted dz's, sexually active but not monagamous, workers with occup exposure to blood, clients or staff of institutions for dev disabled, correctioinal facility inmates, illicit drug users, DM65 - also post partum women HC workers, adults in close contact with infants < 12months old - one time Tdap booster if not already given

Answer 360

40% premenopausal women Tx: supportive bra b/l throbbing discomfort during luteal phase Education, reassurance, well fitted bra Inc'd activity without use of supportive bra may exacerbate discomfort 20% resolve without intervention If supportive bra dosen't work - and severe persistent pain - try danazol Can try tamoxifen if supportive bra doesn't work - off label use for cyclic mastaliga - rarely a/w hot flushes/mentrual irregularity Cyclic mastalgia dx'd if PNA, pleuritis, Myocardial ischemia, infection, costochondritis ruled out If no palpable mass or skin/nipple changes - no need for dx mammo

Answer 361

DX: lumbar pct showing inc'd ICP with otherwise normal findings Cl features: young obese woman, visual disturbances, tinnitis, progressive h/a, papilledema, normal brain MRI CN VI palsy false localizing sign aw elevated ICP No carotid US - carotid lesion won't cause elev ICP or isolated CN VI palsy No CT sinus - CN VI palsy and papiledema localizes to Intracranial cavity not sinuses - if 2ndary h/a invovling paranasal sinus cuased this they would extend into cranial vault which would show up on brain MRI and MRV No MRI cervical spine - tension h/a would not cause CN VI palsy and papiliedema

Answer 362

Mucosa associated lymhpoid tissue (MALT) Gastric associated lymphoid tissue lymphoma tx: flagyl, amoxicillin, omeprazole 14 day course MALT lines digestive tract providing immunosurveilence Malignant transformation of MALT B cells is consequence of chronic antigen stimulation (from H.pylori infxn in context of gastric ulcers) removal of antigenic stimulus -> complete and durable remission Involved field radiation tx - large cell gastric lymphoma or MALT lymphomas unresponsive to antimicrobial tx - Chemo (rituximab or cyclophospamide, vincrisitine, prednisone) only if unresponsive to antimicrobial tx Don't just observe - maltoma will eventually progress and disseminate requiring more toxic therapy than abx+ppi

Answer 363

Pt with liver dz (hemochromatosis) - at increased risk of necrotizing fasciitis 2/2 vibrio vulnificus infection after eating raw or undercooked shelfish(oysters) or following expoure of traumatized skin to contaminated sea water (warm brakish water ie gulf coast - esp summer months) Hemochromatosis - with evdience of portal HTN (ascietes) Pt with liver dz p/w sepsis and cutaneous manifestation of hemorrhagic bullae after possible exposure to waterborne, gram neg rod (Vibrio) - inc'd iron availability inc's virulence and growth of vibrio (in addition to decreased opsonization and serum bactericidal activity found in pts with liver dz) - Tx: cephalosporin/tetracycline

Answer 364

babesiosis - tick associated infection - occurs in NE/upper midwest - flu like sx 1 week after infection from tick - Peripheral smear shows intraerythrocyte parasites (maltese cross or ring form) NO RASH - worse in pt with decrased splenic fxn Tx: atovaquone/azithro

Answer 365

G neg rod from dog or cat bite cellulitis -> overwheling sepsis (pt with dec'd splenic fxn) Tx: Augmentin

Answer 366

``` RMSF Rash - palms soles wrists/ankles -> moves to center (trunk) maculopapular->petecial No hemorrhagic bullae Tx: Doxycycline ```

Answer 367

Use MTX WITH TNF alpha inhib further reduction in Dz activity and radiographic regression ongoing mod dz with eleve CRP and synovitis despite MTX +adalimumab to MTX/folic acid/prednisone Need aggressive tx to minizize sequellae (etanerecept, infliximab, adalimub, golimumab, certolizumab all same) ALways screen for TB first (can reactivate latent TB) if + then treat before starting TNF Do not d/c folic acid with MTX - decreases GI/hep toxicity of MTX - Don't d/c MTX - use with TNF Don't use sulfasaszine instead of MTX - less effective would not improve and bad with RA with poor prognostic factors Don't just continue MTX - need to escalate tx

Answer 368

INtermediate risk - framingham 10-20% CRP can reclassify intermediate risk to either low or high pt may benefit from initiation or intensification of pharmacologic therapies such as statins JUPITER Trial - hypothesis that middle aged healthy pt with elevated CRP and LDL < 130 - would benefit from statin therapy - showed ARR of 1.2% Pt with no cardiac sx does not need stress echo or CT angio BNP elevated and releaed from cardiac myocytes with inc'd preload, afterload or increased cardiac wall stress NOT inflammatory marker - not used to guide intensity of tx for primary or secondardy prevention Pt with high BP should be rechecked, lifestyle mod discussion,

Answer 369

Pheo can cause paroxysmal HTN, diaphoresis, h/a, anxiety Surge in BP can be 2/2 catechol release from tumor such as pheo chromaffin cells derived from neural crest secrete norepi - sustained or episodic HTN Diaphoresis, palpitations, h/a (classic triad) wt loss, dyspnea arrythmias (atrial/ventricular) catechol induced myopathy measure 24 hr categholamine/metaneph in urine or plasma metanephrine(easier) Therapy: first alpha blockade (terazosin) then surgical removal Only after pheo biochemically confirmed get CT (MIBG scan) No catheter angio of kidney - dangerous to stim pheo again and likely not RAS No reason for echo

Answer 370

Monitor LFTs q3-6 months in pt with immune tolerant hep B infection High circulating VL but no signs of inflammation (usually pts from endemeic area where acquired perinatally) As long as LFTs normal - low likelihood of liver dz If at some point AST/ALT elevate then should be treated No role for vaccine - pt already with viral load and is immunotolerate not making Ab Liver bx only if AST/ALT elevated - if has inflamm or fibrosis - start therapy Don't start therapy now - pt immunotoleartnt and not likely to progress to liver dz as long as liver fxn tests normal -

Answer 371

Offspring of mothers with prepreg obesity and then gestation DM at risk for childhood obesity Gestation DM - usually ID'd 2nd trim Woman's B cells can't compensate for degree of insulin resistance due to placental derived factors Dx based on OGTT Could be due to genetic factors and maternal imprinting of genes during intraunterine life Women with gestation DM likely to develop GDM in future preg and DM2 themselves Maturity onset DM of young - aw genetic defects on enzymes or trascrition factosr but not getational DM Type 1 DM - autoimmune - 1A - autoab vs beta cells or their products - anti-glutamic acid decarboxylase, anti islet cell, anti-insulin 1B - idiopathic - no autoimmune markers - asian/african Neither aw gestational DM

Answer 372

Long acting morphine indicated in cancer pt with persistent pain throughout day or beyone 24hrs of tx with short acting opiods Also give short acting for breakthru pain (should uptitrate long acting till good sustained pain control achieved (initial dose 30-50% pts current 24 hrs need) Fentanyl patch takes 24 hrs to start working - should not be started on DAY OF DISCHARGE Methadone - unpreicatable halflife - QT prlongs/arrythmogenic - if used need tomonitoring QTC - not ideal fo rlong term pain control Don't use difffernt short acting opiods - would interupt sleep with need to take more pain meds

Answer 373

Eaton Lambert aw Small Cell lung CA 50% EL pt have SCLC - 3% with EL syndrome Eaton Lambert - rare NMJ transmission d/o from ab againsst P/Q voltage gated (presynaptic) Ca Channels Sx: prox limb wk, absent DTR, dysautonomia - dry eyes, mouth, constipation, ED Improveemnt of DTR/muscle strength with brief isometric excercise (facilitation) Dx: EMG testing/assay for P/Q CC Ab Myasthenic syndrome not aw thymoma, carcinoid, fibrosing medisatinitis Pulm Carcinoid - centrally located ENDOBRONCIAL tumor or solitary pulm nodule no mediastinal mass Fibrosing mediastinis - infiltrative process obliterating fat planes - no focal mass Thymoma - aw Myasthenia gravis - anterior mediastinal mass

Answer 374

Polypharmacy frequent morbidity in elderly Overmedication in elderly pt taking many meds Inc'd diuretic can cause overdiuresis/vol depletion - leads to dec'd kidney ability to clear kidney cleared drugs Pt older than 65yo take many meds - Need routine review of meds AKI not clearly cause of AMS Always consider infection as cause of AMS or FTT in elderly Neurologic exam should be focal to consider stroke...

Answer 375

Bone scans can't diff osteoporosis from other bone mineral dz NOT resposnive to bisphosphonates Only if bone bx confirm osteoporoiss use it in GFRt tolerate vit D analogs because of tendency to develop HYPER CAlcemia - FDA approved for ESRD and hyper PTH For pt with stage 4 CKD - target for PTH is normal range Sevelemir for pt with kidney dz and hyperphophatemia Ca supp shold be 2gm /day or less between diet, suplement and calcium containing phos binders

Answer 376

Pt with high risk adenomas (>3-10 adenomas, >1cm, villous morphology, high grade dysplasia - size doesn't matter) NEED surveillence colonoscopy 3 years later (assuming complete colonscopy was performed to look for other cancer Repeat colonscopy 2-6 months for sesille adenomas removed piecemeal to ensure complete removal Colonoscopy 1 year - fhx of hereditary colorectal CA syndromes - or risk factors like inflamm bowel dz (UC/Crohns) Coloscopy 5-10 yr for one or two small (<1cm) TUBUALR adenoma with LOW grade dysplasia

Answer 377

Traid sx - fever, h/a, focal neuro defects (only 50%) 1/3 are cryptogenic if >2.5cm - shoudl do CT guided aspiration for definitive dx microbioligic and histopath testing Do not LP - has midline shift - could cause brain herniation Whole body PET or CT shoudl not be performed prior to confirming mass is abscess vs tumor

Answer 378

Panretinal laser photocoagulation - results in PRESERVED central vision with DECREASED peripheral vision (where burns applied) - noticable at night More bloodflow to central retina as burns to periphery stop neovascularization Visual acuity should stay same, not improve or deteriorate Binocular and depth vision fxn of central vision so unaffected by laser photocoagulation

Answer 379

Secondary OA inovlves joints not typically affected by primary OA Check transferrin saturation to dx secondary OA 2/2 hemochormatosis OA of MCP/PIP/wrist in absense of trauma unusual - should investigate for hemochormatosis Shoulder/hip/knee/ankle Check Xray - for osteophytes(hook shaped), joint space narrowing Secondary chondrocalcinosis Serum transferrin and iron sat ANA - not needed = SLE can cuase inflamm arthrtis in RA distribution but non-erosive No other sx of SLE (rash, serositis) RF - dx of RA - not if asym joints with osteophytes/joint space narrowing Not gout - so dont check urate - no tophi - distribution diff

Answer 380

Pt with h/o multiple first trimester miscarriages Dx'd PE +lab results - dRVVT 2 weeks apart, anticadriolipan, B2glycoprotein Need mixing study for protonged PTT ATIII def - inc'd r/o VTE - early in life and pregnancy morbidity - usually genetic - should have fhx VTE Factor V Leiden - 5x r/o VTE - is aw preg mrobidity But NOT 1st treim miscarriages MTHF redcuatase mut - mild to mod hyperhomcysteinemia modest inc'd r/o VTE - not aw preg loss

Answer 381

Progressive MF leukoencephalopathy Natalizumab for MS look out for new or worsening neurologic sx If any suspicion on brain MRI - CSF tap for JC Virus PCR IF + stop natalizumab and plasmapehreis to remove circulating Ab Mitoxantrone - dose dep cardiotoxicity IFN - flu like sx Glatamir acetate - skin lipoatrophy at injection site IFN beta - worsening underlying depression

Answer 382

Locoregionally advanced - Stage III, IVa/b without distant mets Radiation, chemo +- surgery Need multiple moadalities to attempt optimal therapy Chemo only if distant mets (cisplatin) - too diffuse for radiation Early stage (I & II) - surgery or radiation with curative intent

Answer 383

If aortic root >5cm - urgent surgical repair Marfans - tall and thin, armspan > height, pectus deformity, long thin fingers, scoliosis, ectopia lentis (or just myopia) Murmur = AR No symptoms so no need for urgent hospitalization, IV bp meds or emergency surgery needed Oral lsoartan and metoprolol - reduce rate of aortic root dilation in marfans if caught early - won't help if already >5cm No f/u TTE - already large aoritc root needing surgery

Answer 384

Decompressive surgery best chance for future ambulation Spinal cord compression from met to vertebra which then extends and compresses spinal cord Need to dx and treat before motor symptoms Corticosteroids should also be administered right away then decompressive surgery then radiation Androgen dep therapy - gnrh agonist or sugical castration - adjuvant in high risk prsate dz - or first line in pt with incrasing PSA after initial therapy or with mets Chemo not effective for met cancer causing spinal cord compression unless highly sensitive (ie lymphoma) Radiation therapy - better after surigcal decompression (head to head surgery better)

Answer 385

Omalizumab (anti IgE) - severe asthma with evidence of allergies and high IgE levels - refractory to high dose ICS and long acting B2 agonist therapy - Reduces frequency of attacks/exacerbations r/o anaphylasxi Very expensive d/c if no improvement in 6 months No role for MTX, azathroprien for severe asthma TNF alpha doesn't help asthma