Deck 4 Flashcards

Question

Manage shock in hospitalied patient

Answer 1

First volume resuscitation and monitoring in ICU Si of shock - low arterial/CVP, tachycardia, tachypnea, CV sat < 70%, oliguria, acidosis, delirium, cold extrem, livedo reticularis Vasopressors only if volume resusitation fails or life treatening hypotension PRBC only if active bleeding, profound anemia, CAD, hypotension/lactic acidosis, Hg 7-9 ok Hydrocortisone - not needed if fluids/vasopressors get pressure to SBP>90 - use in refractory shock

Answer 2

No specific meds to reduce risk of CRC Just do routine screening according to risk factors No evidence for ASA/NSAID/HRT (also bad because of r/o breast and endometrial CA) - blood thinners - more r/o bleeding than reduction in CRC risk (also HTN, kidney impairment, hemorrhagic stroke)

Answer 3

1st line - carbamazipine (or oxcarpabzipien) 2nd line - gabapentin Sx: older pts -paroxysms of face - pain in face/forhead - 2nd/3rd branches of TG nerve - seconds to mnutes with specific trigger points Need MRI brain to r/o small but present r/o intracranial lesion If herpes zoster/shingles cuasing TG nerve pain would also have vesicular rash - no need for acyclovir, valcyclovir, famciclovir Medically refractory TG neuralgia could be tx'd with microvac decompression via craniotomy prednisone - cluster h/a, temporal arteritis, would have elevated ESR/CRP - abn MRI?

Answer 4

Refer for surgical eval - cervical radiculopathy with progressive motor deficit and defined anatomic ab (herniation with nerve compression) on MRI -> surgical eval to avoid permannet loss of fxn Without progressive motor deficits - conservative approach ok - rehab/PT, local steroid inj (faster reilef) continue analgesics and rest - all inapprporitae if progressive motor deficits

Answer 5

Pt with preop COPD exacerbation - delay elective surgery should tx COPD exacerbation prior to surgery if elective Broncodilator tx - corticosteroids and abx prevents post op pulm complciations (lung infxn, atelectasis, inc'd airflow obstruction) Risk factors: smoking, poor helath status, COPD severity Early mobility, incentive spirometry, deep breathing all dec periop pulm complications Stable COPD does not require repeat PFTs if had recently Roflumilast - PD4 inhib for chronic tx of pt with SEVERE COPD and h/o recurrent exacerbations Don't just go ahead with surgery - needs optiization and tx of COPD/exacerbation

Answer 6

PPX rifaximen - reduce r/o traveors diarrhea in pt with inflamm bowel dz (or immunocomp illness, CAD) highest risk mexico, south/central america, asia, africa (not south aftrica) Def: 3 or more unformed stools/day, abd pain, cramps, n/v bloody stools, fever Usually self limited Enterogenic E coli - salmella, campylobacter, vibrio, shigella, norovirus PPX only recommended in pt with risk ie inflamm bowel dz - usually cipro used but resistance occurs Use rifaximien instead Avoiding tap water does not confer much benefit but should do so anyway Bismuth slaicylae is toxic and does not work well Probiotics efficacy uncertain in travelors diarrhea Antimotility agent ie looperamide not effective

Answer 7

NSAIDS - ie celicoixib - inhibit renin synthesis - hyporenemic hypoaldosteronism - decrease K excretion - hyperkalemia Transtubular K gradient - ratio of K in collecting duct to peritubular capillaries - TTKG=(Urine K/(Urine osm/Plasma osm))/Serum K TTKG normal diet 8 or 9 >10 in hyperkalemic state - reflecting excretion of excess K+ Low TTKG - defect in kidney K excretion in presence of high serum K -> likely NSAID toxicity B/l adrenal hemorrhage - adrenal insuff - loss of glucoand mineralocorticoid activity - also with hypotension, flank pain, fever, nausea High K intake - rarely cuase of hyperK in pt with normla renal fxn - if tha twas case TTKG would be >10 Pseduohyperkalemia - in setting of plt>400, excluded if pt has EKG changes c/w hyperK

Answer 8

Elderly pt with painless jaundice focal cutoff sign of bile adn pancreatic duct with upstream dilation Next: EUS for detecting tumor (more senstiive than CT for small tumors) - and can bx tumor if found MRI not as sensitive Don't use Ca 19-9 for screening or dx tool Whipple should not be performed until defiintive dx made

Answer 9

Change to linezolid Good in lung tissue for MRSA/VRE s/e myelosupp (esp plts) - weekly CBC Not Dapto - bound by surfactant - can't tx PNA -is good for staph bactermia, R endocarditis, skin/soft tissue infxn, good for VISA where requirement for vanc is high Don't use rifampin - resistance grows quickly Don't use tigacycline - only for CAP - not for Vent assoc PNA or HAP

Answer 10

D/C offending drug - infliximib - on TNF alpha inhib - develop - ANA, anti DSDNA, Anti Sm, Phototoxic skin rash - > likely DILE if autoab also + Can use hydroxchloroquine to tx RA but need to d/c offending agent for DILE first Don't combine TNF alphas - marginal benefit and higher risk of infxn Can increase MTX in absense of DILE if active synovitis occurs with MTX+TNF

Answer 11

D/C heparin, monitior plt and start argatroban HIT - dec'd plts 5-7 days after tx with heparin for DVT or other reason Dx: Plt 4 ab or Serotonin release asssay need argatroban and warfarin DTI argatroban (cleared thru liver) Don't use lepirudin - cleared thru kidney - in pt with CKD! No enoxaparin - will exacerbate HIT - also contraindicated with CKD Don't use fondaparinum - no evidence of efficacy with HIT and cleared by kidney so can't use in CKD Don't just stop heparin - needs tx

Answer 12

Urine pot-Cr ratio = UK+ x 100/U Cr Ratio >20 - Renal K wasting hypokalemia Furosemide - blocks K uptake in thick ascending loop of henle and thru hypovolemia casuing secondary hyperaldo - further K losses in urine - K-Cr ratio should be >20 though Vomiting/NGT loss - does not do much as most loss in this case 2/2 urinary K loss - K-Cr should be >20 Need very high bicarb and alkameia to shift that much K into cells...

Answer 13

``` constellation 2 GI sx 4 pain sx 1 pseduoneurologi 1 sexual sx Unexplained persistent sx Start before age 30 Need to diff from depression with somatic features ``` Malingering - concisouly fabricate sx for some secondary gain - somatiform d/o are unaware sx are manifestation of psych d/o - need h/o secondary gain Celiac dz - wt loss, GI sx - no focal neuro sx MS - can cause nausea - MRI neg so likely not MS, no somatizataion sx in MS

Answer 14

D/C buproprion and start setraline (SSRI MC rx'd depression med with sexual s/e) Goal - achieve complete remission 6-12 weeks into tx and continue 4-9 months - check in at 2-4 wks for drug adverse rxn, suicide risk, - 6-8 wks for respones - use PHQ-9 to assess nature of response Need at least 50% reduction in sx Complete responder - continue tx for 4-9 months Partial responder/non-responder - higher dose(already max), add 2nd drug or switch to new drug or psychotherapy(doesnt want) Don't use buspirone - anxiolytic - no anxiety sx Don't continue current therapy ifnot working at 8 weeks - change to diff drug in same class or diff drug ECT - suicidal pt or severely depressed - psychotic features - need rapid response - pt not suidcial

Answer 15

Excercise stress echo - pt with LVH with strain on resting EKG Pharm stress indication - cant excercise, LBBB (false + anteroseptal rev defects on imaging at increased HR caused by excercise) Stress with imaging - abnormal resting EKG - LBBB, Vpacing, ventricular pre-excitation, major ST-T abn, LVH with repol CMR - not for finding ischemia - can show prior infarct/scar - also excercise gives additionial prognostic info.

Answer 16

Pt with unexplained fever and polymyalgia rheumatica - or for pt with suspected Giant cell arteritis whose temporal arter bx neg - get CT or MR angio of neck and chest - PMR - hip/shoulder girdle stiffness/pain GCA - can be confined to great vessels - need imaging of great vessels No need for BM bx - without leukopenia/thrombocytopenia and normal smear (no exp of cuase of fever/joint pains) Kidney/mesenteric angio - dx of polyarteritis nodosa - should also have abd pain, HTN kindey dsfxn or mononeuritis multiplex MRI hips/shoulder limited use in pt with minimal PE findings

Answer 17

Post menopausal woman with ascites and pelvic mass on US 1st step - paracentesis and cytology exam 70% women have met dz beyond pelvis at dx any palpable ovary druing exam shoudl be suspicious for ovarain CA - nuliparity and tob inc'd r/o ovarian CA BRCA not useful - only one 2nd degree relative with breast CA likely not syndromal No need for lap and bx at this poitn - paracentesis better first step - used for definitive staging if first step + Cervical CA not likely given age and normal cervical exam CA-125 - can't be used to dx ovarian ca - not sensitive or specific - can be used to monitor after dx (also elevated in other dz's PID, peritonitis, endometriosis)

Answer 18

Ankle splinting... ankle radiograph only if can't bear weight or bony tenderness to palpation at posterior edge of either lateral or medial maleolus Grade II ankle sprain - partial tear of one or more ankle ligament - mod pain some difficulty bearing weight - NSAIDs, rest, elevation and ankel splint - no surgery +- rehab No need for corticosteroid injection MRI only if simple ankle sprain don't resolve with conservative measures or complex ankle sprain Urgent surgical referral - grade III ankle sprain - complete ruputreof one or more ligaments - pw severe swellign, echymosses, instability, inablity to bear weight

Answer 19

Cluster h/a - severe unilateral pain orbitotemporal region 15-180min aw ipsilateral tearing/rhinorrhea, motor restlessness male/tob user cluster in 6-8 weeks, remission 2-6 months Tx: Oxygen therapy No amoxicillin for cluster h/a (or for sinusitis) - absnse of fever/purulent nasal d/c argue against sinusitis No hydrocodone for cluster h/a Oral sumitriptan doesnt help cluster h/a (SQ/IN do) Verapamil/corticosteroids for PREVENTION of cluster h/a not tx of acute episode

Answer 20

Lung volume reduction surgery - reduces hyperinflation, improves efficiency of resp musclees, improves exp flow - only in highly select patietns as is very extensive surgery 1. b/l emphysema on CT 2. post broncodil TLC >100%, RV >150% predicted 3. Max FEV1 45 room air 5 - upper lobe emphysema better No reason to inc O2 if O2 sat >=88% Long term corticosteroids - limited if any effect Pulm rehab not defiitive therapy

Answer 21

Tx: tylenol along with antinausea - metochlopromide/ondasetron non-pharm tx ice, hydration Tylenol cat B Migrains can cause adverse preg outcomes low birth weight, preeclampsia, placental abruption, preterm delivery No reason for ppx - too few attacks - adn amytripline cat c Naproxen - can't use during 3rd trim (PDA closure, materanl bleeding at delievery) Oxygen for cluster h/a not migraine Rizatryptan - Cat C - don't use before tylenol

Answer 22

Finish remaining cycles of chemo Tx: 6 cycles of ABVD - stage IV Hodkins poor outcome regardless of initial therapy Pt with neg PET after 2 or 3 cycles of chemo have high likelihood of complete and durable remission with compeltion of cycles of chemo In pt with +PET after 2 to 3 cycles - need intensification of chemo with bleo, etopiside, doxorubicin, cyclopho, vincristine, procarbazine, prednisone - also early high dose chemo and autologous stem cell support No need to bx LN in on residucal LAD not visible on PET because results unlikely to show viable malignant cells Total LN irradiation NOT needed - particularly with bone inovlvement not effective in achieveing complete remisiion and can limit additionial therpay 2/2 BM suppresion

Answer 23

all people age 13-64 should be screened for HIV screening effective even in low prevelance settings - particulary effective given HAART therapy availability need to confirm Ab test with western blot (don't western first - high false +) Cholesterol screening: screen all pt 20-35 with increased CV risk, age 35 for pt with no CV risk NCEP guildine - start screening at age 20 then q5yr if normal DM screening - for all adults with BP 135/80 or greater Screen all adults 45 Screen all adults BMI>=25 with one or more additional risk factor - gestation DM, HTN, HLD fhx DM2 in 1st deg relative Hypothyroid - no agreement on screening - USPTF does NOT recommend screening

Answer 24

Needs AVR complicated infective endocarditis - HF, abscess, fistula, severe Left side valvular regurg, refractory infxn despite abx therapy, recurrent embolic event esp with vegetation >1cm NO delay in surgical intervention if surgical indications are met - complication likely won't improve with medical therapy alone - likely worsen and increase operative risk No reason to add rifampin for viridins strep - needs surgery Cath not indicated - inc'd r/o emboization - worsending HD status - cath only prior to planned valve replacement if r/o CAD Heparin does not reduce embolic events with vegetaivie lesion endocarditis

Answer 25

``` C - onfusion U - BUN>19.6 R - RR>=30 B - BP65yo Score 0-1 outpt therapy Score 2 or more hospitalization Score 3 or more consider ICU ``` ICU? - need for vasopressor or mech vent minor criteria - confusion, hypothermia, hypotension requiring fluids, multilobar infiltrates, aPO2/FIO2 20 3 or more minor criteria -> ICU Do not D/C pt need inpt therapy

Answer 26

Most deisrable nutrition approach = enteral via NGT need to supply hypermetabolic state - prevent mucosal bkdn, prvenet infection, loss of lean mass, assist in wound healing Feeding thru stomach NGT best as keeps GI tract working and prevents atrophy Even with burns and airway injury tolerate NGT placement J-tube placement only if concern of regurg or if upper GI tract not working - J-tube perc also source of infectioin, no benefit in aspiration risk or reflux Can't do TPN thru peripheral - limited volume possible not enough given high metabolic needs from burns TPN thru central line - high risk of infection - particularly with burns - maintanence of access (needs to be changed), GI tract will atrophy, trace element deficiency, high cost - only use if parenteral options tried and failed or not tolerated

Answer 27

d/c tenofovir (drug related damage to mitox - particularly in renal tubules) Prox RTA (II) glycosuria in normglycemia hypophosphatemia (dec'd prox tubule absorption of Phos 2/2 damage from tenofovir) proteinuria Urine pHd tubular sec of Cr (reversible - not kidney damdage), no change in true GFR) No role in check lactic acidosis - if elevated would cause AG met acidosis (this pt with normal gap) Laxative abuse - NORMAL gap met acidosis - laxative induced bicarb lossses exceed ammoniagenesis so get metabolic acidosis with normal AG

Answer 28

Flavivirus - MC mosquito borne viral illness in world Carribean/Latin america/southern US fever chills, frontal h/a, retroorbital pain, msk pain/arthraliga lower spine - nonsp maculopapular rash sparing palm/soles Incubation 4-7 days "breakbone fever" leukopneia, neurtropenia, thrombocytopenia, mildly elev LFTs prolongued fatigue Full recovery usually tx: symptomatic (no vaccine) Leptospirosis - urine or tissues of infected animals - (rodents, small mammas) - self limited - fevers, myalgia, abd pain, conjunctival suffusion - RARE rash Malaria does not cause rash Yellow fever - subsaharan africa, SA NOT carribean

Answer 29

myeloprolif d/o - elevated plt count - in absnse of other conditions causing thombocytosis(secondary) >1 million plt strongly suggestive HSM possible r/o reactive thrombocytosis - IDA, underlying inflamm d/o, cancer Dx: plt >600 on two sep occasions >1 month apart BM: hypercell marrow with megakaryocyte hyperplasia (morp abn), mega in clusters 50% JAK2 CML - WBC>100, diff all stages of cells IDA - unlikely with normal Hg and normal MCV P Vera - unlikely with normal Hg

Answer 30

bacterial infection of biliary tract (CBD) choledocolithiasis usual cause Charcot triad - RUQ pain, fever, jaundice - septic shock and confusion -> reyanaud pentad elder pt may not have fever, leukocytosis or abd pain Empiric abx imaging may not show ductal dilation or choledocolithiasis ERCP=dx/tx - if high clinicial suspcion - also can tx while in there - bililary decompression Broad spec abx No chole in acute choangitis scenario - only after resolution of acute cholangitis HIDA - looks for acute CHOLECYSTITIS MRI with MRCP - clincial evidence of cholangitis and need for possible intervention - not possible with MRCP

Answer 31

3% saline txment hypotonic hyponatremia - SIADH (low serum Na and high urine osmol, high urine Na) Uosm>200, UNa>40, low plasma Osm, no evidence of hypovolemia correct 4-6meq in 24 hrs if too fast - osmotic demyelination (cells shrink as water goes out of them) if >10meq then reverses with D5W +-desmopressin (ADH analog) Do not use NS - will cause more Na out than H20 and make hyponatremia worse Lasix only with asx chronic hyponatremia 2/2 SIADH - causes more dilute urine to be excreted Tolvaptan - oral V2 vasopressin rct antagonist - asx euv/hypervolemic hyponatremia - causes free water diuresis ADH - keeps free water in and causes hyponatremia (inappropriately in SIADH) Tolvaptan blocks ADH receptor and fixes hyponatremia

Answer 32

Wt loss an excercise needed Obesity most important modifiable risk factor for knee OA Tibiofemoral knee OA - pain worse with weight bearing tibiofemoral joint space narrowing and osteophytes Risk factors: obesity, age, Female, joint injury (overuse, trauma, occupation), genetic factors Wt loss/excercise better than NSAIDs No celecoxib - inc'd myocardial risk in pt with CAD - can also cause dyspepsia No effect of glucosamine sulfate in reducing pain MRI knee - eval for meniscal or ligamentous injury - not needed if no locking of knee or neg exam for ligament or meniscal tear (ant drawer, post drawer, varus/valgus)

Answer 33

Pregabalin or SNRI (duloxetine, milnacipran) for fibromayalgia with or without depression Fibromyalgia - widespread pain/tenderness for at least 3 months - fatigue, sleep disturnabce - mood d/o, cognitive impairment Non pharm tx: aeorobic excercise - CBT Fibromyalgia NOT inflamm conditioln - won't respond to steroids or NSAIDs (NSAIDs may help in conjunction with SNRI) No good evidence for SSRI in fibromyalgia

Answer 34

Colonscopy in 1 year after hemicolectomy If possible endo/CT imaging studies to ID and remove synchronous malignancies Colonoscopy in 2-6 months ONLY if preop colonoscopy can't go through whole colon - need to go back and inspect whole colon early - removal of synchronous polyps - still need surveillence colonoscopy 1 year after surgery

Answer 35

uncomplicated faint - no further testing required if physical exam and EKG normal 3 P's P=posture - occured uring prolonged standing - similar prev episode aborted by lying down P=provoking factors - pain/medical procedure P=prodromal sx - sweating, feeling of warmth right before faint Pts with situataion faint, orthostatic hypotension - shoudl undergo EKG but no further testing if physical exam and EKG ok Hospital telemetry - undx syncope with known structural heart dz, high risk for arrythmia Neuroimaging HCT - limited use - highest yield in >65 with neuro symptoms - h/a, neuro exam abn, head trauma, on A/C Echo - if str heart dz suspected - ie murmur Tilt table - suspected neuro not confirmed by history and physical exam - , recurrent episodes - and with suspected cardiac cause

Answer 36

Sx: dyspnea, pedal edema, clear lungs, JVein engorgement Elevated RH pressure - JVP, hepatojug reflux, pedal edema, Kusmall sighn (jugular vein engorment with INSPIRATION) - ECHO - restrictive filling, ventricular interdependence (diastolic filling of one chamber impeding other - normally free walls would bulge out to accomidate but in constrictive pericarditis thickened pericardium doesn't allow that) to and fro motion of IV septum Cardiac CT with pericardial thickening Complciation from CABG (risk factor - violated pericardium at some point) Restrictive CM - cardiac amyloid - dypnea, right sided failure, restrictive ventricular filling - increased wall thickness - NO LVH NO ventricular interdependence Cardiac tamponade - dypnea and JVD - need pulsus paradoxus >10mm Hg (abn decrease in SBP with inspriation >10mmHg) Severe TR - dypnea/pedal edema, elevatged RH pressure Holosystolic murmur - would see TR on echo

Answer 37

Progesterone stabilizes endometrium stops uterine flow Medroxyprogesterone acetate for menorrhagia of known etiology (fibroid) Estrogen/prog OCP - doses too low in combo pills to affect heavy bleeding If pt orthostatic or dizzy then IV estrogen ok r/o PE/VTE Don't just observe as pt has heavy bleeding

Answer 38

congential X-linked d/o normal PT, prlonged PTT - corrects with mixing study fully Post op and traumatic bleeding is severe compartemnt syndrome is manifestation of bleeding diathesis (epistaxis, hemarthrosis) Replacement of deificient factor is treatment of choice recurrent hemarthrosis results in cripplling degenerative joint dz unless treated with factor replacement CNS hemorrage also occurs ASA/NSAIDs contraindicated Aquired F VIII inhibitor - normal PT, prlonged PTT - INCOMPLETELY corrects with mixing study Factor V def - prolonged PT AND PTT Factor XII def - normal PT, prolonged PTT but NO BLEEDING associated

Answer 39

Excessive elaborate gait that varies in appearance from moment to moment (inconsistent) - non-neurologic inconsistent with lesion in CNS unconvincing displays of weakness, extremem lurching without falling Dx gait with chorea, dystonia, tremor, myoclonus hard to dx but with prolonged observation are consistent in pattern Peripheral injury dystonia, PSTD with dystonia, Reflex sympathetic dystrophy - fixed dystonic posture coupled with pain, sensory chagnes and autonomic instability of limb

Answer 40

Tx: Tizandine, baclofen, cyclobenzaprine UMN spasticity 2/2 MS and hyperreflexia impaired gait 2/2 stiffness PTx and anti spasticity drugs No need for EMG - pt has normal CPK (so no inflamm myositis) or NM d/o (ALS) MRI lumbosacral spine - only images lower spine - PE findings c/w upper spinal cord or brain lesions Oxybutynin treats bladder spasiticty/overactivity - not a sx in this patient

Answer 41

Pt with painless rectal bleed - likely from colon - MCC is diverticulosis PE unremarkable unless large bloodloss -> tachycarida, orthosatsis, hypotension Coloosocpy can ID diverticulosis and also r/o AVMs - tx both with epinephrine/electrocautery Colon CA - rarely causes brisk arterial bleed - usually chronic occult blood loss Melena - suggests UGIB - 150-200cc blood - hematochezia from UGIB suggests at least 1L blood - pt would be hemodynamically unstable Ischemic colitis - sudden temporary reduction in mesenteric blood flow - hypoperfusion affects "watershed areas" (splenic flexure/rectosigmoid jnc) - can have dizziness pw sudden onset crampy abd pain - bloody stool/bloody diarrhea

Answer 42

Needs PFTs and echo Skin involvement only in face and extrem distal to elbow Dx lcSS - tightness/thickening skin swelling digits extending proximal to MCP Without skin changes need 2 of following Sclerodactyly terminal digital pitting/ulceration basilar interstitital fiborsis on CXR ANA+ antecedent h/o raynauds r/o PAH in ABSENSE of other pulm manifestations need PFT/TTE for early detection of PAH Esophageal dysmotililty common with LcSS but no need for barium esophogram if no sx of dyphagia HRCT - needed only with sx of dypena or impairment of oxygenation with restrictive pattern on PFTs - not indicated without pulm sx or abn PFTs RHC indicated with dyspnea or PAH noted or PAH noted on echo

Answer 43

Adjuvant chemo used to improve disease free survival after hemicoloectomy removed all visible cancer Improving "disease free survival" increases period without recurrance - ie disease relapse delayed or even prevented Clinical Benefit rate - outcome of cancer therapy given palliatively instead of for curative intent - with metasatic dz tx may only stabilize and not shrink tumor, sum of measurable complete and incoplete responsders as well as disease stability is clincial benefit rate Disease specific survivial - percentage of patients alive without have recurrance of dz - excludes death from tx or other cuases wheether related or not - goal of adjuvant therapy is survival not just prevention of cancer recurrance and death Aduvant chemo does not decrease risk of second GI cancer or other GI malignancies

Answer 44

``` asyx benign murmur < 3/6 early and brief systolic lack of radiation absnese of additional heart snds emotional few extra beats NO ADDITIONAL TESTING NEEDED for asx benign murmur with no associated findings of valvular or cardiac dysfxn ``` Ambulatory EKG - 24-48hrs - continuouis or event activated - not indicated for brief palpiations without hemodynamic abn Only for repetive frequent palpitations TEE - pt with poor imaging via TTE, or to evaluate surgical repair feasiblity of valves TTE - systolic murmur 3/6 or greater, any diastolic murmur, continuous murmur, holosystolic murmur, late systolic murmur, ejection clicks, murmur radidating to neck or back

Answer 45

Need to get ABG In pt with dyspnea and somnolence - high chance of arterial hypoxemia from alveolar hypoventillation - with CO2 retention Normal O2 sat on pulse ox does not exclude hypoxemia in setting of HEAVY smoking - carboxyHg high - false high O2 sat on pulse ox No need for chest CT CBC might show inc'd Hg in setting of long standing hypoxemia -not useful acutely Echo not needed - might show elevated RH pressures 2/2 COPD/ corpulmonarle

Answer 46

Add spironolactone Pt already on standard med tx (BB, ACEi) NYHA III-IV EFt inc BB with low HR and borderline BP

Answer 47

Sx: Young man with with solid food dysphagia - foods stick in mid esophagus - occ heartburn, no issue with liquids - no wt loss - recent disimpaction of food EGD - rings in esophagus - bx >15 EOS/field Need to first exclude GERD which can also cuase EOS infiltration of esophagus - either PPI trial or ambulatory PH monitoring If neg for GERD Tx: swallowed aerosolized fluticasone EGD dilation on if refractory to medical therapy (dont do early - inflamm makes mucosa fryable - r/o rupture) No role for food allergy testing

Answer 48

systemic necrotizing vasculitis - affect upper/lower resp tract and kidneys can have upper airway - sinusitis, orbital/nasal, laryngeotracheal inflammation Pulm sx - cough, hemoptysis, pleursy CXR: MF infiltrates/nodules- may CAVITATE Pauci immune glomerulonephritis (erythrocyte casts) Initial clinical feature may be inflamm of salivary glands - if untreated saddle nose deformity, nasal septal perf, Sarcoidosis - inflamm lesions of orbits, trachea, nodular lung infiltrate - necrotizing sarcoid granulomatosis - intersitital nephortis not aw glomerular dz (no erythrocyte casts) Sjogrens - salivary gland enlargement with lung infiltrates - trach inflamm/nodular/cavitary lung lesions absent may cuase interesitial nephritis but NOT glomerular dz TB - can invovle cervical LN but rarely in adults - can also be in Submandibular glands but does not explain glomerulopathy

Answer 49

need to r/o underlying UTI - check U/A first nocturia, urinary frequency, hestiancy, retention, incmplete bladder emptying, incontinence Post void residula - not needed for BPH - used for overflow incontinecne or neurogenic bladder Elevated glucose - can cause freq/nocturia from osmotic diuresis but not weak stream or hesitancy No reason to check PSA TRUS - evaluatiion of prosatte CA - rarely causes lower urinary tract sx

Answer 50

Add acetazolamide Metabolism of citrate from excess blood products -> prdocution of excess bicarb-> metabolic alkalsosis Pt with cirrhsois - less renal blood flow - impairs kidney bicarb excretion (increased prox tubular reabsorbtion of bicarb) - increased bicarb load and met alk Acetazolamide - promotes bicarb excretion also dumps sodium Lasix dumps NaCl but not bicarb - will actually worsen situation because pateint will become hypovolemic and experience contraction alkasosis then even less renal perfusion - Isotonic saline - will not increase bicarb excretin - sodium cl will be retained from inc'd prox reabsorbtion of Na in setting of low renal perfusion - worsening ascietes/fluid ol Octretoide - splancnic vasoconstrictor - used as adjuvant after endoscopic therapy for variceal bleed - - does not do anything about met alk - no need to dc

Answer 51

Pt has had definitive surgery for back pain 2/2 spinal stenosis and still has pain out of proportion for post op - not participating in PT 2/2 pain - not tapering pain meds - has risk factors for drug dep - fhx etoh abuse, age < 45, smoking, Needs pain managment contract Amitrylpline good adj tx but need to address opiod use first - If have to use opiods - change to long acting tough not appropropiate for long term pain No focal neuro so no imaging needed

Answer 52

Pt with cavitation and no known risk factor for HAP - tx for CAP (Strep pneumo, H flu)+CA MRSA PNA ceftriaxone, azithro, vancomycin Scenario - viral URI seems to be improving then suddenly worse - CA-MRSA superinfection

Answer 53

``` Tenofovir induced nephrotoxicity mitochondrial damage to renal tubular cells (prox RTA II) Fanconi like syndrome Glycosuria despite normoglycemia Phophaturia causing hypophos AAuria mild proteinuria normal AG with LOW bicarb in serum low urine pH (distal tubule still fxn in acidifying urine) ``` Hep C assoiated glomerulonephritis - significant hematuria/proteinuria/RBC casts immune complex d/o HIV associated focal segmental glomerular sclerosis (collapsing form) high VL, nephortic syndorme with high level proteinuria Atazanavir - nephrolithiasis

Answer 54

Supportive care only close f/u, immunizations, folic acid Cl ft - splenomeg, fhx, leg ulcer/pigmented gallstones 2/2 chornic hemolysis - spherocytes on smear Pt still able to goto college and run so fatigue no limiting - mild anemia stable PPX Cholestyecotmy controversial - if knwn choledocolithiasis then ok No benefit for pednisone for hered spherocytossi - treatment for AUTOIMMUNE hemolytic anemia More severe dz with sx anemia, splenomeg, sk changes, extramedullary tumors - respond well to splenectomy

Answer 55

Empiric doxy regardless of cause for EM Either lyme or southern tick associated rash illness both ticks endemic to Virginia Erythema Migrans - expansive, target like lesion Don't need boriella burgdofi PCR skni testing with EM present - just treat IV ceftriaxone with cardiac or neuro lyme manifestation No need for B. Burgdori serology - false neg with early lyme or southern tick associated rash illness - just treat

Answer 56

Post ICU neuropsych impairment - up to 75% aw pt age, duration of vent, glycemic control eps with severe sepsis or ARDS Aquired dementia correlated with hypoxemia Not chornic DIC = would have issues with low plts and thrombosis Critical illness polyneuropathy - risk factors - steroid use, NM blocking agents, DOES NOT AFFECT COGNITION not likely if regained muscle strength Prolonged NM blockade - aw paralytics in pt wtih liver dz - does not cause cognitive impairment

Answer 57

Check serum Cr to assess degree of kidney fxn - the worse the Cr/GFR - worse outcomes - r/o eclampsia, pre eclampsia + possible irrev decline in kidney fxn Women normal shoudl be t predict preg outcomes HTN aw CKD - not predictive of preg outcome - no need for amb BP monitoring If dx known no need for repeat kidney bx - preg outcomes depend on level of kidney fxn not etiology kidney dysfxn

Answer 58

``` Lumbar polyradiculopathy Primarily muscles of thigh L2-4 Severe pain at onset followed by weakness/numbness over coming weeks aw DM - period of wt loss ``` DM Polyneuropathy - axonopathy - distal to prox sensory loss, parasthesias, pain, distal LE wk Absnet/dec achilles reflex, stockig distrib sensory loss Guille barre - no thigh pain - numbness and weakness symmetric start distally and radiate PROXIMALLY, tendon reflexes hypoactive in both legs Meralgia parathetica - lateral femoral cutaneous nerve of thigh, sensory loss only over lat thigh, NO motor/wk sx

Answer 59

First step in sleep eval - sleep diary Insufficient sleep syndrome ID number of hours sleeping/night No need for EEG if no sz suspected Polysomnography - if OSA suggested - less likely in young thin man without obvious upper airway ab - reasonable if sleep diary etc neg Multiple sleep latency testing - establishes dx of narcolespy - done after insufficent sleep excluded and PSG r/o OSA

Answer 60

Gastric bypass hx Deficiencies: B12, iron, Ca, folate, 25 hyroxy vit D, Also copper, Mg, zinc, Vit A, B complex, Vit C Pt with Myelopathy (hyperreflexia/upgoing toes) -> localizing to posterior columns/b/l corticospinal tracts B12, copper, neurosyphillis Copper def also aw macrocytic anemia (zinc def, malaborbtion, nutritiondef) Folate def not aw myelopathy Vit D def not aw myelopathy Thiamine def - wernike korsekoff - NOT myelopathy Vit A def - blindness, benign idiopathic IC HTN (pseudotumor cerebri) - not aw myelopathy

Answer 61

Stage I/II - chemotherapy and radiation doxorubicin, bleomycin, vinblastin, dacarbazine (ABVD) Sx: palpable LAD or mediastinal mass Hodkins highly curable in any stage Never radiation along - some cases can do chemo only Single agent rituximab - only role in lymphocyte predom CD20 + hodkins lymphoma Don't just watchful wait - always treat hodkins as highly curable at any stage

Answer 62

Corticosteroid and IVIG - need rapid rise in plts 2/2 bleeding Dx of exclusin - bleeding in setting of otherwise normal CBC (except low plts) - or organ dysfxn - Need tx if plts t use rituximab Splenectomy is only for refractory ITP (to med tx - last resort)

Answer 63

recurrent episodes of fever h/a, vomiting, photosensitivity meningeal inflamm w/o known bacterial or fungal cause Usually virus HSV-2 - meningitis (HSV-1 encephalitis) genital lesions of HSV-2 preceed meningitis CSF low leukocytes, higher/normal gluc, gram stain neg Bacterial meningitis CSF - leukocyte 1-5K, neutrophils, glucose <100 cells Acute retroviral syndrome - fatigue, fever, pharyngitis, LAD rarely CNS sx Rash - diffuse maculopapular extrem, back, - not pruritic

Answer 64

dependent symmetric b/l le edema compression stockigns, sodium restriction, leg elevation, weight reduction venous insuff Lower abd/pelvic imaging not needed (only if suspect lesions obstructing venous/lymph return) - not likely in otherwise healthy woman No need for diruesis - may lead to orthostatic hypotension don't reliably move fluid from interstituim to vasc space in setting of venous insuff LE venous duplex - r/o DVT - if no concerning sx or risk factors then no need for scan

Answer 65

IV Gancyclovir DDX odynophagia - infect esophagitis (HSV, CMV), pill induced esophagitis -tetracycline, iron, bisphosphonates, KCL, nSAID, quinidine CMV - isolated deep ulcers with CMV inclusion bodies Acyclovir - HSV infection only - not CMV - multiple superficial ulcers (not deep), GG nuclei, mutinuc giant cells on histo - +PCR for HSV Fluconazole - for candida infxn - dysphagia not odynophagia - curdy white dep that adhrere to mucosa Swallowed aerosoized fluticasone - tx for eosinophillic esophagitis

Answer 66

recurrent 12-72hr episodes of fever with serositis (abd or pleural), synovitis(monoarticular, LE), erysipeloid rash sx begin in childhood few times/year kidney amyloidsos can occur in untreated ppl Tx: colchicine reduces likelihood of acute attacks and amyloidosis

Answer 67

fever, rash, joint pain, serositis (pleural or pericardial) Fever < 4hrs (not upto 72) Rash - salmon colored - not painful trunk/prox extrem VERY ELEVATED FERRITIN

Answer 68

progressive fatigue, diarrhea with abd pain, wt loss, fever, estra abd manifestation - arthritis, skin rash, (erythema nodosum or pyoderma gangrenosum) - usually chornic not brief episodes

Answer 69

monarticular arthrits but no fever or abd pain | +uveitis, urethrtis, arthritis

Answer 70

Mechanical hemodyn support for pt in CV shock with no improvment with iontropic agents IABP placement - reduces afterload Evidence low CO - cool extrem, AKI, confusion, elev LFTs, vol o/l (elev RAP, PCWP) Conivaptan - vasopressin rct antag used to tx SIADH (hypervolemic hyponatremia) PAC shows low CO even with ionotropes - can't use diuresis while SBP still unstable - first IABP then possible diuresis Nesiritide - pure vasodialtor - natriuretic/diuretic effect - NO IONOTROPE OR VASOPRSSOR effect - don't use in setting of hypotension

Answer 71

Tx: SSRI, CBT Sudden panic attacks - acute onset somatic sx ie chest pain, palpitationis, sweating, nausea, dyspnea, numbness "feeling of doom" 5-60min aw agoraphobia r/o cardiac, thyroid or pheo not typical GI sx so no PPI, no cardiac risk factors so no reason for cardiac testing

Answer 72

Cuteanous sclerosis that involves ONLY skin - no systemic manifestations Hx similar to systemic sclerosis but no systemic sx Limited - one or more discrete plaques of skin Diffuse - can invovle limbs/trunk No extracut sx ie GI, GERD, raynaud Diffuse cutaneous systemic scloersis - skin thickening involving areas prox to elows/knees Limited cutaneous sytemic sclerosis - skin disease that doesn't progress prox to elbows/knees linear scloerderma - skin thickening followed by dermatomal distribution on one side of body

Answer 73

Pt with fasting hypoglycemia (5-6) likely has insuloma - if not seen on CT then should get EUS MRI no better than CT Penteotide scan not eff for insulioma - not enough somatostatin rct to be effetive When preop localization not psosible then operative exploration needed

Answer 74

Vancomycin + 3rd gen cephalosporin gram+ dipolococci -> S pneumoniea CSF with low gluc, high WBC, high protein Can't just treat with ceftx, no levoflox

Answer 75

ICD placement Risk factors: Fhx premature death 1st deg relative Ventricular wall thickenss >30mm ->ICD indicated Pt with LVOT obstr, HF sx refractory to medical tx - septal myotomy or etoh septal ablation indicated (not if asx) No EPS - pt with HOCM not reliable to risk stratify for SCD No need for checking for blunted BP resposne during exc if already has 2 major risk factors Amiod can be considered to prevent SCD in pt with HOCM with one or more risk factors - if ICD implant not feasible Physical activities - only low intensity - golf/bowling, not basketball/bodybuilding etc

Answer 76

Calcium gluconate needed perioral numbness, anxiety, vomiting, neuro instability during plamsa exh = calcium def Citrate used chelates calcium NS won't correct hypoCa diphenylhydramine only if rash/hives/utricaria Epi only if anaphylaxis Heparin - only if PE

Answer 77

non-prod chornic cough without apparent cause check sputum for EOS No airway responsiveness on challenge testing - differnetiaes from asthma Tx: trial inhaled corticosteroids - need bronchial muc bx for def dx No need for sinus imaging try antihistamine/decong first Diet/lifestyle mod and PPI trial prior to 24hr manometry to r/o GERD

Answer 78

bilevel Pos pres airway decreases nocturnal pCO2, daytime pCO2 and sleepiness inadequate alveolar vent Dont NEED sleep study but helpful CPAP only for OSA - and hypoventillation during sleep - this pt with NM wk has daytime hypercapnia also CPAP only maintains airway patency (ok for OSA) but does not augment ventillation DOn't use just supp O2 can depress ventillation and worsen hypercapnia (if used only with BIPAP) Trach - only if can't tolerate non inv vent or has trouble handling secretions -

Answer 79

Fhx of CKD - should check Cr eGFR, u/a (blood, protein, casts) also if h/o DM, HTN Kidney US - only if h/o polycystic kidney dz in family or abnormal CKD screen 24hr urine cr precise estimate of kidney fxn only in case o fliving donor tx candidates Radiouclide scanning - gold standard but expensive - only used occasionally

Answer 80

Pt with budd-chiari -> aw myeloprolif d/o like essential thrombocytopenia or p vera Hepatic vein thrombosis UQ pain, hepatomega, rapid jaundice/ascities, elev LFTs + finding -> need for cytoreductive therapy CHeck for JAK2 V617F mut Essential thrombocytopneia - >600K plts Antiphospholipid syndrome - aw first trim preg losses, SLE - usual sites of thrombosis (art/venous) - calves No associated thrombocytosis Paroxysmal nocturnal hemoglobinuria - CD55/59 on flow cytometry not aw thrombocytosis complememnt med hem anemia unusual area for thrombosis (splenic vein) AT3 def - protein C def - autosomal inherited (dom/rec) - inc'd r/o VTE esp in calf but NO THROMBOCYTOSIS

Answer 81

``` Check sweat chloride +clubbing, upper lobe bronchiectasis Sweat Cl>60 then gene testing Milder cases can be misdx as asthma - then find to be hard to control ``` No need for dx bronch now Echo - clubbing and suspected of congential heart dz - no other stigmata ie loud murmur, asym pulses, HF, cyanosis - no TTE for now Diary of asthma sx and peak exp flow good to assess asthma control - but does not explain bronchiectasis and clubbing.

Answer 82

EKG with prolonged QT - likely 2/2 haldol which does inc QT should d/c haldol keep K>4, Mg>2 Risk factors: age, femaile, use of multiple QT agents - diuretics, impaired hepatic drug met, bradycardia freq PVC, h/o long QT syndrome Should avoid QT proonging drugs in future Dig, dilt, enox, bactrim don't affect QT Exc dig can cause acc jnc rhtym, reg afib, atach, HB, PVC, VT, VF Dilt - AVB or sinus brady

Answer 83

Severe cdiff = WBC>15 and Cr >1.5x baseline Tx: Flagyl 10-14 days even for 1st recurrence NO long runs of flagyl - neurotox Oral vanc only for severe c diff Oral vanc + IV flagyl only for pt who drugs won't reach distal colon (illeus/toxic megacolon) 2nd recurrance - prolonged vanc taper 4-8wks

Answer 84

Use pravastatin - renally metabolized instead of hepatic | Goal t use rosuvlstatin with warfarin - will inc INR

Answer 85

``` Glomerulopnephritis Nephritic hematuria +cryoglobins low complement (C4) +RF Palpable purpura, arthralagia, periph neuropathy, Bx: capillary microthombi, diffuse IgM/cryoglobulin dpeosition in capillary loops ``` Polyarteritis Nodosa - systemic necrotizing vasculitis aw Hep B - bx vasculitis WITHOUT immune complex depsoition in glomeruli Hep B - immune complex glomernephritis - would have labs showing active infxn Thrombotic microangiopathy -microangiopathic anemia+thormbocytopenia - no depositoin of immunoglob/complement

Answer 86

Need to check serum iron stores - iron, TIBC, ferritin anemia in CKD 2/2 low EPO, EPO resistance normocytic/chromic, low mcv, low retic IDA - iron/TIBC = transferrin sat = low ferritin >100 excludes IDA ferritin 100, TF sat >20%

Answer 87

Need formal driving assessment - pt has visuospatiail task difficulty so could hinder driving - pt insistin gtha the is ok not reliable Shouldn't just relinquish licence or insisit on supervised only driving if unfounded use clinical jusdgment based on hx - accidents, aggressive impulses/control issues, reduction in ability to manage own affairs, impaired spatial processing and executive fxn - Daytime only driving won't help - issue of visual processing not vision impairment

Answer 88

Pt with primary sclerosing cholangitis -continued intrahepatic duct inflammation/destruction r/o cholangioCA - presentation is biliary obstruction/biliary stricture Dx: ERCP - get cytoloic brushings/bx Abd US not needed - show abn ducts as seen on MRCP - can't do bx with US alone CA19-9 NOT SPECIFIC do not use No need for AST/ALT monitoring at this point - need bx from ERCP

Answer 89

``` Pt with MSSA prosthetic joint infxn Not resonsive to nafcillin still sx Now joint loosined Needs surgical removal of joint high WBC, very high ESR/CRP +synovial ctx after complete resolution new joint can be placed ``` Refampin only with early joint debridment with MSSA IV Vanc only for MRSA joint infxn

Answer 90

Dx: 10^3 CFU in Uctx Sigh/sx - new onset fever, rigors, chills, AMS, malaise, lethargy, CVA tenderness, flank pain, acute hematuria In pt with SC injury - inc'd spasiticity, autonomic dysreflexia, sense of unease no other source of infxn Cloudiness or +gram stain not dx of UTI LE in urine not dx of UTI but if neg good NPV

Answer 91

Despite good lifestyle/excercise Pt with fhx early MI and LDL 196 - needs statin therapy Goal s CV risk

Answer 92

Check lipid profile after starting Tocluzimab only start after TNF fails for RA Can inc serum transamiases, leukopenia, thrombocytopenia and inc chol Pt had normal other labs (LFT, CBC prior to last tx 2 wks ago) Just need to check chol/LDL esp in pt with risk factors for CV dz No cardiac tox - no need for EKG/TTE No effect on Ig - so no need to check serum Ig

Answer 93

ARDS - inc PEEP - inc's Oxygenation by recruiting atelecatatic (collasped) alveoli 6mL/kg ideal body weight Persistent hypoxemia -how to fix 1. Inc PEEP (inc to level of FIO26mL/kg under ARDS NET Nitrix oxide not shown to improve sruvival - vasodil improves V/Q mismatch

Answer 94

3 lesions in right liver lobe - likely mets from colon CA - no reason to bx as will not change fact that she needs curative resection - R hepatic lobectomy No hepatic artery embolization as this is not cruative an only for palliation of HCC/neuroendocrine tumors Radiation tx - rarely used in tx of mets, not curative Don't use pall chemo if there is possibility of cure

Answer 95

``` ABCD2 Score Age: one point for Age>60 BP: one point for BP >140/90 Clinical hemiparesis : one point Duration: 2 points if >=60min ``` 3 or more points - hospital inpt eval - stroke eval and monitor for recurrence Don't use both ASA and plavix unless CAD - no risk red in stroke but in'cd r/o hemorrhage (cerebral) No outpt ECG monitoring - pt needs admission

Answer 96

Even if pt is on diet/oral meds at home - stress of surgery may require insulin during perioop period - shoudl use both long and short acting Don't use oral agents - variable ability to eat and absorb - hard to titrate as longer acting ISS - inferior to basal + bolus Goal of post op keep Gluc < 180 not overly tight control

Answer 97

Repeat CBC in 1-2 weeks Asx, plt >50 in last trimester=gestational throbocytopenia If < 50 in 1st trim - then ITP No intervention if plt>50 , no IVIG, plastma exch, steroids, emergent delivery

Answer 98

Risk factor for PAD - age, smoking (prior), HTN, HLD diminshed peripheral pulse and hair loss in legs Resting ABI normal (>0.9) -> still high clinical suspicion check EXCERXISE ABI dec of ABI >20% dx of PAD Only get contrast imaging if PAD dx made, fails med therapy and evaluating for intervention MRI lumbar spine - lumbar spine stenosis - shuld also have dec'd DTR at ankles Segmental Plethysmoography - pt with established PAD - to localize lesion - drop in BP 20mm or more = zone of decreased persion/sig dz

Answer 99

Sustained sinus tach - indictiative of suture leak Need upper GI series with contrast (water soluble) to dx leak at anastamosis site Fever, abd pain, sinus tach CT angio to r/o PE - less likely without hypoxia, tachpnea EGD contraidicated if anastomatic leak found No emergent surgical exp as pt is hemodynamically stable - even if not found on contrast UGIS (or CT abd) and index suspicion still high - might need ex lap

Answer 100

Women - should be treated like stage III ovarian CA - Surgery-> chemo Monitor CA 125 for response No radiation for abdomen too much small bowel s/e Too early for palliative care - need to treat

Answer 101

IFN-B - flu like sx ELEV LFTs lymphopenia worsening underlying spasticity, depression, migrains Persissent elev LFT may need reduction or cessation of IFN MRI, retinal exam, BUN/Cr don't directly montor s/e of IFN

Answer 102

Maintain urine collecting bag below level of bladder so flow always outward Foley For stage 3/4 ulcers on buttocks hand washing, sterile placement, securing, closed sterile drianage, prevent back flow No benefit to cleaning meatus No benefit to abx coated catheters No benefit to tx asx bacturiia in NON pregnant pts No benefit in routine change of catheters

Answer 103

Sleep study to dx OSA With P Vera - EPO level is suppressed by autonomous inc in Hg from myelprolif d/o If EPO inc'd - dx is 2ndary erythocytosis 2/2 likely sleep apnea (snoring, obesity, wife witness apnic episodes) Tx: CPAP PV - non sp sx ie tinnitisu, blurred vision, h/a - prupritis after taking bath**, erythromelagia (burning sensation palms/soles - plt activ), splenomeg - Tx: therapeutic phlebotomy and low dose ASA can try hydroxyureas if doesnt work No need for BM bx - hypercell marrow can be in both p vera and secondary erythrocytosis

Answer 104

Pretest prob of elderly pt with atypical angina is intermediate - needs stress test Baseline EKG changes so needs imaging Unable to excercise 2/2 advanced OA needing upcoming surgery Pt with severe reactive airway dz - cant use vasodilator pharm stress (adenosine/regadenosine)-> use dobutamine Dobutamine stress echo Don't go directly to angio - needs stress first (atypical angina)

Answer 105

Acute onset painless blurry vision/optic disc swelling Blood and thunder (cotton wool spots) dilated/tortuous veins, flame shaped retinal hemorrhages Afferent pupillary defect (light shined in affected eye no effect - shined in opposite eye causes affected eye to constrict) Older pt with HTN and atherosclerotic dz aw cartoid diss, inc'd visc (p vera) Tx: no particular tx - investigate etiology

Answer 106

narrowing of anterio rchamber angle impedes trabecular drainage Painful - dec vision, halo, red eye, dilated pupil, firm globe, exam either normal or optic dis cupping Tx: meds

Answer 107

``` 50-70yo painless abrupt blurring or loss of vision morning hours affernt pupillary defect PALE retina cherry red spot (fovea) box caring in blood vessels ```

Answer 108

diminished vision, photopsia (flashes of light) multiple floaters, abrupt onset, wavy vision Trauma or spontaneous Distorted folding/tearing retina allowing fluid to pass underneath

Answer 109

Asx patient with indolent, well circumscribed small carcinoids Observation and repeat imaging in 3-4 months low grade on bx normal blood serotonin no evidence of carcinoid syndrome (flushing, diarrhea, wheezing) Hepatic artery emboliz if growing or sx liver mets of carcinoid RFA - ok for limited number of mets No reason for chemo as pt asx, low grade

Answer 110

CHADS2 =5 (>2) then need stop warfarin and provide bridging A/C LMWH or UFH and withold morning before surgery -can't just stop warfarin - high risk of thomboembolic event Dont continue warfarin till surgery or 1/2 dose - INR too unpredictable CHADS 2 or less - ok to stop warfarin without bridging

Answer 111

TNF alpha Drug induced lupus fever, myalgia, non blanching purpuric rash, arthritis, hem, pancytopenia, proteinuria, active sediment abn +ANA, +anti-DSDNA DILE with OTHER MEDS - anti histone Ab+ +ANA +Anti single stranded DNA If DILE and infxn r/o - then r/o underlying LAD/lymphoma with CT Don't use RF/Anti CCP to follow RA flare - doesn't change, will be positive

Answer 112

TTE with agitated saline contrast detect R-> L shunt TTE already showed mile RVE, mild pulm HTN Fixed split S2 -> ASD (in normal study with no shunt - bubble only seen in RA then dissipate in pulm circulation - don't opacify LA) DOnt need cath for detection of cardiac shunt (intracardiac) Don't use microbubble - will opacify both sides of heart in normal heart (doesnt dissipate) - caution with severe HF/sev pulm HTN SPECT CT tagged RBC not useful for dx of shunt (intracardiac)

Answer 113

Moderate persistent asthma (>1 night/wk wake uP) + daily daytime sx No signs of infection Already on short B2 and med dose ICS ADD LONG ACTING B2 DO not double ICS - at high dose get systemic s/e - adrenal supp, cataracts, glaucoma, osteopenia, skin thinning, check for good inhaler technique Ipratropium enhances B2 agonist effect in acute exacerbation but not good for long term Abx not used for routine asthma control

Answer 114

Induction: Plasmapheresis, cyclophosphamide, corticosteroids maintenance: azathroprine, corticosteroids Sevre small vessel vasculitis -> rapidly progressive glomerulonephritis and pulm hemorrhage Things that can cause RPGN - ANCA+ small vessel vasculitis, Exclude infection prior to immunosupp Induction therapy WITHOUT plasmapheresis - only for moderatly active vasculitis (Cr < 5.8, no need for HD) and without pulm hemorrhage No efficacy trial for myocopheilate mofetil/corticsteroid induction+maintanance Don't just use plasmpheresis for ab cleanup - wihtout immunosupp agents will just happen again

Answer 115

NYHA class improving - sx improving (fxn capacity) resolution of constrictive findings on TTE No pericardial fibrosis, Ca, refractory HF COntinue conservative tx with anti-inflamm drugs Transient form from CTD, infection (TB), chemo, trauma, pericardotomy, malignancy No need for endomyocardial bx and R/LHC - used to diff constrictive vs restrictive CM but with restrictive filling and ventricular interdependence - very likely CONSTRICTIVE pericarditis Percardectomy only for progressive constrictive pericarditis in pt with NYHA II/III not with transient cases

Answer 116

rare autosomal dominant Early onset HTN with met alkalosis, hypoK, suppressed renin/aldo 24hr cortisol normal so NOT CAH, cushing, 5 alpha red def Tx: Amiloride(also reduced lithium uptake so given in case where have nephorgenic DI in setting of lithium tox but can't stop lithium) or Triamterine - inhibits sodium uptake No pheo - no h/a sweating, palpitations No primary hyperaldo - serum aldo supporessed - (primary kidney sodium retiention and expanded ec vol Not renovasc HTN - renin/aldo would be inc'd

Answer 117

Normotension - 140/90 in office with 2 sep measurements <140/90 outside office - absnese of end organ damage (ie LVH) Use ambulatory BP monitoring to dx

Answer 118

All subsance addition (etoh, tob, drugs) in last 6 months contraindic for lung tx Need to quit smoking first Tx candidate if deterioration continues despite maximal medical therapy - BODE - BMI, obstruction, Dypnea, Excercise index BODE>5 - lung transplant eval BODE 7-10 - tx indicated if - h/o hopsit for exacerbation of hypercarbia OR pulm HTN OR cor pulmonale OR FEV1 transplant Pulm rehab effective but not substitute for lung tx

Answer 119

``` D/C hydrocodone Drugs that can lower testosterone: Opiods high dose corticosteroids hormonal tx Low testosterone can dec libido, energy Check MORNING testosterone (secretion is cyclical) ``` Metoprolol/BB can cause ED and fatigue but NOT lower testosterone No need to recheck morning testosterone before d/c hydrocodone Only start testoserone replacmeent if still low after all testorone lowering meds are d/c'd if possible

Answer 120

Hereditary nonpolyposis CRC syndrome (LYnch) (HNPCC) "3-2-1" rule - (3 affected members, 2 generations, 1 under 50) HNPCC associated CA = uternine, ovarian Surveillance at age 20-25 or 10 years prior to youngest affected family WHICHEVER EARLIER then q2yr until age 40, then q1yr also need GYN, GU cancer screenings Colonoscopy at 40 - non-syndromic fmaily hx of CRC 1. One first deg relative Colon CA after 60 or 2 2nd deg relatives - colonsocpy at 40 then q10yr 2. 2 first deg relatives or 1 first deg relative before age 60 - colonscopy at 40 then q5yr Colonscopy age 50 - average risk patient Stool DNA or CT colonography are not substitute for colonoscopy

Answer 121

D/c on 7 days oral amoxicillin hospital day 3 afebrile, RR 90, pulse <100, , normal MS, oral intake fine BCTx showed sensitivty to PCN - so d/c on narrow spec ampiclliln - no need for levofloxacin No need for 14 days tx - quick clinical response to abx - so ok for 7 days No need to observe on oral abx

Answer 122

Check and demonstrate inhaler technique (age, eyesight, dexterity, cognitive fxn, degree of lung fxn, btreathing pattern) mod COPD long acting cholinergic, long acting B agonist, adherent Don't add ICS until confirm inhaler technique ok O2 therapy only if O2 sat t restart corticosteroids - not havening exacerbation - no benefit, many s/e

Answer 123

Duplex US - diff between pseduoaneurysm and AV fistula Bruit (continuous) heard Vasc complications: pseduoaneursm, AVF, hematoma, chol emboli, RP bleed Determine if endovasc or surgical intervention needed Don't need ABI - normal would not exclude pseduoany or AVF No need for CT - would be ok for suspected RP bleed but would also have back/flank pain - with hypotension - but pt likely to unstable to take to CT (from proximal pct of cFa in setting of A/C) No need for LE angio - only if diminished LE pulses - or concern for dissection of femoral artery - if distal pulses ok no need - if has dissection may need angioplasy/stent

Answer 124

TTE for diastolic murmur shows LA mass - high risk of embolization and stroke Needs surgical removal EVEN IF ASX No need for catheter bx of mass - only do this if RA mass and if likley to be malignant - allows for dx No F V leiden test - is a mass not thrombus Warfarin not needed for stroke prevention with LA myxoma - efficiacny not proven - not appropriate if pt can have mass resected instead COnsider carney syndorme in young pt with myxoma - look for spotty skin pigmentation, endocrine tumore (ACTH independent), schwanommas

Answer 125

Ground glass nodules need MORE than 2 years of yearly CT f/u with no growth to be conisdered benign - may be slow growing adenoCA in situ (bronchioalveolar cell CA) GG=focal or diffuse opacification of lung parenchyma Can be adneoCA insitu, focal atelectasis, fibrosis, inflmmation atypical alveolar hyperplasia GG adeno can have doublding time of 400 days - f/u at least 5 years GG may not change in size but character - ie becoming part solid - strong indicator of malignancy Don't use PET - GGO have low uptake on PET so lots of false neg's until lesion becomes solid Don't resect - just continue yearly CT unless change seen Don't needle bx - hard to interpret on path

Answer 126

Cancer of unknown primary presenting as axillary LAD in women should be considered breast CA (stage II) Tx: Mastectomy with LN dissection Occult primary found in mastectomy even if mammo and MRI normal DOn't just excise LN - need to assume breast CA and do mastecomty Potentilaly curable so don't just give chemo or radiation

Answer 127

``` Lights criteria pleural protein:serum protein>0.5 = exud pleural LDH:serum LDH>0.6=exud Pleural LDH >0.6 ULN serum LDH If borderline in setting of diuresis then likley transudative ``` SAAG >1.2 = transudative Serum protein to pleural protein >3.1 = transudateive Not due to malignancy - if due to malignancy then would be unilateral, lymphoctic pred, PNA - exudative effsuion but also with fever PE pleural eff - usally small and b/l - exudateive

Answer 128

IV Colistin Pseduomonas with pan resistance in ICUs Patietns with burns particularly sensitive to pseduoonas colistin infequently used as has nephortox but now reliable vs resistant gram neg Minocycline,rifampin don't have good pseduomonas activity Tigecyline - no pseudomonas activity

Answer 129

NPPV after extub reduces need for reintubation - bridge to normal breathing in pt with chronic lung dz and hypercapnia after wheening trial Incentive spirometry reduces pulm complications post op but no role in non surgical patients post extub No evidence that heliox helps dec reintub in pts post extub (easier breathing with lower density air, lower resistance in obstructive COPD pts) N-acetyl cystein - used to thin secretions - no role if already thin - also can trigger broncospasm

Answer 130

Shigella - mild self lim gastroenteritis - to bloody diarrhea with fever Treat pt empirically if very symptomatic or if elderly or imunocompr Patient works in daycare center or NH or food serivce Shigella very infectious even in low concentration Under normal circumstances no need to treat but with DAYCARE WORKER or NH worker or food service- treat with cipro Treatment shortens shedding of virus/diarreha/fever by 48 hrs If confirmed microbiolgically - ok to treat anyway to prevent spread to other people Azithro - empiric tx for campylobacter - high rate of cipro resistance Flagyl - no activity against aerobic bacteria like shigella

Answer 131

Need B2 microglobulin/genetic testing/cytogenetic for prognostic information and time for observ vs treatment ``` Most pt are asx and present with early stage dz discovered incidentally in bloodwork Risk stratification LAD? HSM? Thrombocytopenia? ``` BM bx/asp not needed - prognositic info can be obtained via peripheral blood testing CT scans not needed - won't provide additional info in asx patients PET only if suspect transformation to aggressive lymphoma - will see foci on PET

Answer 132

Recent chemo for AML - risk factor for TLS increase NS to promote faster UOP rate Manifestations of TLS AKI, arrythmia from K, phos, urate Need 6L UOP /day Even with 200cc/hr still high phos and K - need to increase more Can also use loop diuretic to incrase urine flow Don't add sodium bicarb (inc's uric acid clearance by solubiliing but also inc's r/o CaPO4 precip - not good with pt with high PO4 Kayexal will dec K+ but not inc urine flow rate Rasbucaricase - preferred to allopurinol for ppx of TLS - it breaks down urate and minimizes xanthine accumulation- allopurinol does not - if uric acid level ok no need to substitute.

Answer 133

alemtuzumab based chemo and allogenic HSCTx Newly dx advanced stage (IV) - LAD, SM, anemia, thrombocytopenia, elevated B2 microglobulin, unmutated heavy gene 70, 17p deletion Criteria to inititate tx - B cell sx (fever, wt loss, night sweats), sx from LN enlargement, HSM, worsening cytopenia HSCT not used in CLL often becuase median age 70 - can't use in that age cyclophosp, vincristine, prednisone, fludarabine, rituximab not optimal for adv dz with poor progn factors

Answer 134

Rhabdo 2/2 FLUCONAZOLE potentitaion of cyclosporin and statin Still need statin because they dec r/o transplant vasculopathy and improve survivial - need good communic between transplant and general Acute rejection - usually asx - incidentally discovered on endomyocardial bx - manifeestation new atrial tachyarryhmia, new onset HF, no inc in CK CMV - flu like, GI sx (colits), leukopenia, hepatitis (elev LFTs) Transplant vasculopathy - coronary dz of transplant - diffuse intimal thickening - MI, high deg AVB, HF, arrest - not likely with normal EKG and neg trop azoles, CCB, antisz meds,

Answer 135

Check vWF assay/activity Pt with personal and fhx mucocutaneous bleeding - autosomal dominant - MC inhertied bleeding d/o low levels of vWF - but fluctuate with sttrss, exc, estrogen, inflamm, bleeding Prolonged PTT not dx of vWF humoral clotting factors usually produce hemarthrosis (except XI) PT prolong - warfarin, vit K def, chronic liver dz inherited factor VII dz (rare) - presents with mucosal, joint, muscle bleeding

Answer 136

Vit D decreases r/o fall - no need to check vit D level Inc'd r/o fall - gen wk, slow gait, recent fall Don't d/c ACEi unless orthostasis Don't give zolpidem - inc'd r/o falls in elderly Don't rx bifocals - inc'd r/o fall

Answer 137

``` Type B lactic acidosis lactic acidosis rhabdo hyperTGA myocardial abn on EKG (j point elev/brugada like) unexplained AG met acidosis Tx: d/c propofol, supportive care ``` No met abn or AG with fosphenytoin Propylene glycol - solvent used in benzo prep - does cause met acidosis but not rhabdo, hyperTGA, myocardial abn on EKG Pyroglutamate acidosis - in pt getting acetaminophen during critical illness - depleteion of glutathione stores 2/2 increased oxid stress - accumulation of pyrogutamic acid

Answer 138

BMI>40, or BMI>35 with obesity related complications ie DM, OSA, HTN, HLD If diet/excercise and meds like orlistat don't work must be well motivated (pt already tried and did not lose weight) eval by med, surg, nutrition, psych gastric bypass, lap band more dramatic and sustained wt loss No phenteramine - only short term use - ppl usually regain weight when stop med Very low caloried diet does not work Excercise alone will not work for massive weight loss

Answer 139

Need to control BP, pt also with hyperK control BP to prevent CKD progression and dec r/o CVD ACEi ideal for BP control in CKD since it slows progression but in setting of hyperkalemia contraindicated INcrease loop diuretic in this case to control BP and lower K+ Pt with CKD need higher doses of diuretic to be effective also will dec IV volume which increase BP in CKD patients Kayexalate may dec K but won't change BP Don't use spironolactoen to control BP, will inc K+ Don't d/c ACEi - will lower K but will worsen BP

Answer 140

Central vertigo - vertigo with VERTICAL nystagmus - immediate, prolonged, non fatiguable >1min on Dix halpike medical emergency Can be ischemia or infarct in brain inability to stand without dysarthria or diplopia - likeley cerebellar MRI brain with angiography - superior sensitivity CT doesn't see posterior circulation Epley maneuver/otolith repostioning - resolves sx of BPPV - peripheral vertigo - minutes, multiple episodes - No tinnitius, ear pain, hearing loss Sx tx for vertigo only for peripheral - URI can cause vestribular labrinthitis however exam incionsistent with peripheral vertigo - on dix halpike should last <1min and fatigues with time and only HORIZONTAL nytagmus

Answer 141

fever, chills, cough, CP, Late post tx timeframe (6 months) high risk for infxn with encapsulated bug (S pneumo) - reason for Pneuomoccal vaccine for tx patients Candida rare cause of PNA CMV - infection usually 1 month after tx - diffuse infiltrates on CXR PJP - not likely while taking bactrim - also not likely lobar pre-engraftemment=100 days - high risk of infxn from encapsulated bugs

Answer 142

In pt with depressive sx need to elicit if hypomanic or manic episodes also -> bipolar d/o Tx with mood stabilizer Lamotrigine Lithium is mainstay but has teratogen, nephrotox, hypothyr alt mood stabiizer - lamotrigeine, VPA, carbamazepine Antipsychotics for frank manic episodes - ariprazole, quietipine If you just give anti-dep will breed frank mania in bipolars Duloxetine - SNRI - depression tx Benzo - lorezepam - infeff for dep or mania - adjunct only for mania SSRI - setraline - may trigger manic episodes in pt with bipolar - if any pt being consdiered for SSRI then make sure no manic sx

Answer 143

Aggressive hydration, HD, Rasburicase malignancies with rapid cell turnover (Burkitts, leukemia) or in pt with bulky dz, high leukoocyte counts aw rapid adn sig senstiivty to chemo (large cell lymphoma, CLL) HyperK, HyperUr, hypophos, hypoCal, AKI, DIC Can't start chemo in this state - need ppx tx for TLS first Once stable can start No radiation for burkitts

Answer 144

Severe HSV in HIV pt with very low CD4 - Suppressive tx-> ACYCLOVIR >6/yr or severe -> ppx also restart HAART Cidofovir, foscarnet - for acyclovir resistant HSV Cidofovir in ointment can hasten healing of HSV lesions can cause ulcers IV Cidofovir - rash neutropenia, AKI Foscarnet - AKI, nasuesa, sz, paraethesia Valganciclovir - tx/supp of CMV not HSV myelsuppresion s/e

Answer 145

Cog Behv therapy somatoform d/o - focused on single real or imagined symptom Needs to be medically unexplained - hense many imaging studies/consults impairment to fxn NO benzo - tolerance/dependence No reason for more imaging already confirmed neg No olanzapine - pt not psychotic Schizophrenia - psychosis is definiing feature - 6 months of sx - 1 month or more of at least 2 active phase sx - halluc, delusions, d/o speech, catatonic beh also neg sx - flattened affect

Answer 146

BP Goal <150/100 Proteinuria known to inc during pregnancy Goal to avoid end organ damage in preg period No reason to add methydopa (sedating effect and BP under control at this point) No ACEi or ARB - teratogenic No reason to inc labetolol - at goal

Answer 147

Don't d/c plavix before cataract surgery for at least 1 year Don't d/c BB if already on BB Dont d/c benzos, narcotics, antisz drugs - all can cause withdrawal

Answer 148

Timed up and go (TUG) aris from chair walk 10 feet turn around and sit back down >14s = inc'd r/o future falls Get details of fall, home risks, list of meds Don't need to d/c ACEi as BP was not low Exc program if suspect weakness or poor balance Need to assess gait and mobility before giving cane/walker

Answer 149

Acyclovir, valcyclovir, famicyclovir Several vesicular lesions with erythematous base, fever, malaise, dyuria dx: viral culture/PCR Chronic tx with valcyclovir prev transmission to sexual partner Benzathrine PCN G - primary syphllis chancres - single painless lession with clean base Ceftx+azithro - mucopurulent cervicitis Single dose fluconazole - candida vaginitis - fissures/excortiations - no ulcers..

Answer 150

``` A neg will have ab vs B and Rh O neg is universal donor - give this in urgent situation AB+ is universal receipient O does not have A or B antigens Rh neg does not have Rh antigens ``` Use of A+ would lead to acute or delayed hemolytic rxn only in emergency if Aneg and Oneg not availble ABneg would not be compatible - acute hemolytic rxn (anti B ab) B+ no good both ABO and Rh incompatible

Answer 151

Women older than 30, no risk factors for cervical CA and no abn PAPs - change to q3 years with cytology or q5yr with cytology and HPV DNA testing ACOG - q2yr 21-29 if all normal then q3yr after 30 if 3 normal consecutive pap and no h/o in utero diehtystibestol exp, no immunocomp, HIV, cervical intraepith neoplasia, Never use HPV alone - poor specificity Don't d/c PAP until 70's at least

Answer 152

Prompt amputation Dense anethesia, lack of pulsees and doppler signal, no active motion If delayed progressive limb necrosis No role for ABI - no PT or DP so can't get reading In less severe limb ischemia (viable or marginally viable) can consider intra arterial thrombolytics MRA not needed - need immediate surgery If limb salvageable then reasonable to proceed to emergency angio/endovascular repair

Answer 153

Pt currently not microalbuinruic - adding ACEi can prevent progression to microalbuminuria interupt renin angiotensin system reducing glomerular filtration Other HTN agents (BB, CCB, diuretics) can lower BP but dont affect glomerular filtration) - so not first line in pt with DM and HTN

Answer 154

Dx: Urine nuleic acid amplicfication for Neisseria gonnococus Also Blood, synovial, mucosal (throat, anus, urethra, cervix - higher dx yiedl than blood/synovial fluid ctx) Likely not inflamm arthritis - can be SLE or RA(usually symmetric) but usually not migratory asymmetric polyarticular like in DGI and no erythema nodosum necrotic vesicopustules on erythematous base HLA27 only + on 50% reactive arthritis - not reactive arthritis should also have conjunctivitis, urethrtis, oral ulcers

Answer 155

Pt with heart transplant and new LV dysfxn / HF sx Syncope, heart block TTE with segmental dysfxn MCC of late ventricular dysfxn in cardiac transplant patients - Chest pain uncommon with CAV as denervation during cardiac tx Diffuse intimal hyperplasia rather than focal stenosis so hard to treat Late rejection after long period of graft stablity rare most rejection in 6mo to 1 year PJP woul dnot explain cardiomegaly, S3, JVD reduced LV fxn Not recurrent myocarditis - should have some effusion

Answer 156

benign proteinuria inc's during the day while standing up other transient/benign proteinuria - febrile illness/rigorous exc Not aw long term kidney dz No further eval needed Kidney bx only in pt with suspected glomerular dz (RBC casts) nephortic syndrome, acute glomerulnephritis or kidney tx dysfxn No reason to repeat 24hr urine collection Spot urine not better than 24 hr no need to do both Normal protein < 200mg/24hrs - don' tjust reassure if not orthosatic proteinuria then could be indicator of early kidney dz

Answer 157

Hypoxemia 2/2 post op atelectasis - pt is extremely obese, now post op in upper abd surgery (bariatric) or lung surgery - inc'd r/o atelectasis and hypoxemia CPAP reduces risk by opening up alveoli Bronch only for complete atelectasis suspect mucous plugging - usually try chest physiothearpy first ALbuterol inhaler only if asthma - no wheezes so likely not asthma Naloxone only if hypoxemia 2/2 hypoventillation from residual anesthesia effects

Answer 158

``` EPO underproduction anemia in CKD normocromic, normocytic, low retic normal iron, TIBC, ferritin Smear - burr cells Still need to exclude GIB ``` Inflammatory anemia - low serum iron, low TIBC, high ferrtin IDA - low iron, low ferritin, HIGH TIBC

Answer 159

29yo F with h/o hodkins with mantle radiation yearly breast MRI and b/l mammo also nulliparus Also BRCA1/2 carriers need yearly mammo b/l and breast MRI Breast US not sensitive enough to detect breast CA No blood tests (CA15-3, CEA, CA 27.29) are for routine surveillance Pt needs screening as is high risk

Answer 160

Long term O2 therapy >15hrs/day PO2 < 88% improves survival, exc capacity, alertness, motor speed No need for abx or predisone if no acute exacerbation or broncospasm First need O2 therapy then consider repeat pulm rehab (has shown culumualtive benefits)

Answer 161

Managing TV start at 6mL/Kg ideal body weight then DECREASE until platau pressure <30 permissive hypercapnia ok Dec RR or inc FIO2 would not affect plateau pressure Inc PEEP would INCREASE plateau pressure

Answer 162

Control BP with IV BB then sodium nitroprusside Type B dissection - med management No dissection flap seen if hematoma Neg D-dimer 95% NPV against aortic diss (<0.5) Chest pain - r/o ACS, PE, aortic syndrome trop I should be elevated 2 hrs after pain starts malperfusion syndromes with aortic dissection - will need endovasc fenesttation or stentting - not needed if no signs of malperfusion Emergency surgery only for type A dissection (ascending) (only B if malperfusion ro significant aneursysmal dilation) No reason for ppx stenting if no signs of aneursymal dilation No A/C as hematoma contained within aortic media - no r/o distal embolization

Answer 163

Benefit from OMT + epleronone (blockade of renin angiotensin system) If pt had ACS, LVEF t inc BB if HR low Only warfarin if afib or LV thrombus

Answer 164

sharp, pleurtic, retrosternal CP - worse with recumbancy (lying down) and deep inspiration pericardial friction rub EKG diffuse ST elev/PR dep (wide, concave up) Antecedent URI (or autoimmune dz, uremia, neoplasm, trauma) No risk factors and atypical story for ACS No EKG changes with pleurtiis No EKG diffuse ST elev/PR dep with acute PE

Answer 165

TEE FIRST if high prob of endocarditis (pt with staph bacteremia, prosthetic valve or fungemia or intracardiac device) Concern for AR (wideneded Pulse pres), aortic root abscess (prlonged PR), Also if aortic diss, LA thrombus, CT not superior to TEE and not good with elev Cr No MRI with GAD in CKD - systemic nephrogenic fibrosis

Answer 166

Need to turn off Shock therapy Need to also change to asynchornous mode (VOO) ICD thinks cautery is Vfib and will shock and inhibit pacing Pt has CHB - pacing dep - so needs VOO No TVP needed - ICD will pace Magnet ONLY disable shock in ICD (will change PPM to asynchronos) If pt has ICD but NOT PPM dep then ok to just place magnet to disable shock therapy Not good if PPM dep as electrocautery would also inhibit pacing

Answer 167

Periodic fever syndrome serosal inflammation in chest, abd, joints erysipelas like rash on lower extremity (raised, erythematous warm rash) neutrophilic leukocytosis Elevated ESR, CRP Tx: Colchicine Sweet syndrome - acute febrile neutrophilic dermatitis - middle aged women with recent URI fever arthralgia myalgia cutaneous lesion rash : tender, nonpruritic, well demarked plaques neck upper trunk upper extrem No abd pain Tx: steroids Eythromelagia - parox b/l erythema of extrem with warmth and pain - precip in warmer temp, dependent position Staph cellulitis - purulence, asymmetric districution - LAD - no episodic occurences

Answer 168

1st line therapy is PDE5 inhibitor for ED sildenafil, vardenafil, tadalafil DO NOT use if on nitrates 2nd line=alprostadil - IU, Intracav(better) - penile pump, prostesis Don't give testoterone rep unless sign/sx of androg def and testosterone <200

Answer 169

Small primary tumor (I or II) Radical hysterectomy or radiation without chemo No chemo for early stage - for adv stage chemo+rad best Stage IA1 - microscopic = LEEP/conization and close observation if want to preserve childbearing inhstead of hysterectomy Pelv radiation + chemo - high risk dz, bulky primary tumor or adv dz (large primary, deep stromal inv, lymphovasc inv, postive LN or surgical margins)

Answer 170

HSV-2 Dx: CSF PCR for HSV-2 Many episodes of meningitis - h/a, fever, stiff neck that resolve spontaneously Transietn neuro episodes - sz, hallucination, diplopia, CN palsy, AMS Occurs without signs of gential or cut infection No need for cytologic studies as likely not malignant with recurrent episodes - WNV - not recurrent MRI brain only if presented with ENCEPHALITIS (fever/hemicranial h/a, language/beh, memory imp, , CN def, - susually HSV-1 not 2

Answer 171

``` Sepsis: Known infection: SIRS - temp >38, 12 20, P>90 4-6L vol in first 6 hrs Early agrrsive fluids improves mortality ``` Only hydrocortisone if shock refractory to fluids AND pressors or h/o adrenal insuff BP ok so no pressors PRBC only if active bleed or Hct<70 after adequate fluid challenge

Answer 172

BK virus infects epithelial cells Screen for BK if see decline in kidney fxn after tx U/A looks like interstitial nephritis (erythro, leukocytes, leukocyte casts) Kidney bx confirms with viral inclusions in tubular epith cells Tx: DECREASE immunosupp as much as poss to avoid graft rejection If doesn't work - flouroquinolones - leflunomide, cidovovir **gancclovir, acyclovir don't work Muromonab CD3 increases immunsupp by suppresting lymphocytes - makes BK infection worse

Answer 173

Young man, 4 week history of fatigue, inermitt fever, sore throat, LUQ abd discomfort No night sweats, wt loss, cough, dysuria, diarrhea soft movable b/l LAD, palpaable spleen Smear: large atypical lymphocytes No rash Dx: Check for EBV (anti EBV ab assay) No need for BM bx or PET - r/o mono first LN bx not needed until mono r/o Peripheral blood flow cytometry - likely polyclonal - doesn't add to dx Only useful in malignancy to check for monoclonal population

Answer 174

Clinician hold onto initial impression (ie dx of referring physician) and doesn't consider other dx's

Answer 175

basing dx on what is on physicians mind (ie saw similar thing last week)

Answer 176

presentation misleading - little opportunity for physician to pick up clues

Answer 177

pattern recog error - appears to fit a typical case but fails to think about other dz that could also fit...

Answer 178

``` Mycoses fungoids (skin) Sezary Syndrome (skin and blood) Cutaneous non-hodkin's lymphoma Skin: dry, pruritic, nonerythematous patches (can be observed or tx with topical steroids) Progression: T cells infiltrate organs/blood/LN -> organomegalzy and dysfxn - Sezary cells: CD4+, cerebriform nuclei Immunodef, recurrent infxns Tx: Sezary syndrome - Alemtuzumab ``` No total body irradiation unless planning stem cell tx Not just observation - organ involvment and immunodef

Answer 179

``` Intraabd pressure>20mm Hg New organ dysfxn (ie AKI) Preceeded by LOTS of fluids (ie 15L post op) or massive ascities or RP bleed Measure pressure thru bladder foley Tx: surgical decompression of abd ``` Tobramycin - can cause nephrotox but not usually 1 dose and does not account for increase'd abd pressure Not from pre-renal - FENA>1% - and unresponsive to fluid resusucitation Not obstruction - no response to foley and no hydro on US

Answer 180

Acute onset of unilateral redness - watery d/c, itching, crusting, diffuse foreign body sensation, mild photophobia Preceeding URI Tx: Cold compressess, don't share towels and hygene things with close contacts, wash hand frequently, may spread to other eye Allergic conjunctivtis - recurrent, seasonal - cobblstoning on upper lid - Tx: topical anti histamines/NSAIDS - no oral antihist Abx (topical) if bacterial conjunctivitis - MUCOPURULENT d/c - Topical steroids - DO NOT USE - if pt has HSV or fungal conjuntivitis can lead to cornela scarring, melting , perforation

Answer 181

Anal CA - SCC Radiation/Chemo - NO SURGERY - results in permannet colostomy Tumor with no mets 5FU/mitomycin Surgery only if cancer recurs or progresses locally after treatment with chemo and radiation **RECTAL CA** adenoCA Needs surgical tumor resection

Answer 182

Indication for ppx 1. Prosthetic Cardiac valve 2. HISTORY of endocarditis 3. Unrepaired cyanotic heart dz 4. 6 months after congential heart dz repaired with syntheetic material 5. Palliative shunts/conduits 6. Cardiac valvulopathy in pt with cardiac transplant Amox or cephalosporin PCN all: Clindamycin, azithro, clarithromycin Vanco not needed - despite prior MRSA - does not choose coruse of abx for present Can't do nothing - pt has indication for abx ppx...

Answer 183

liver failure and sepsis can be distributive shock +SIRS AMS Organ dysfxn (ele cr) Need to ID source of infxn - with ascietes need dx paracentesis r/o SBP No abd imaging until SBP r/o by tap Vasopressors not needed until Map<65 refractory to fluids No role for corticosteroids unless h/o adrenal insuff or pressor/fluids not working

Answer 184

cough and sx suggesting CAP BUT not improved after one or more abx courses B/l diffuse alveolar opacities despite normal lung vol Non-infectious Tx: steroids Chronic PE - progressive dypnea/hypoxia over weeks to months but no systemic sx (fever/chills) - pt without clear risk factors COPD - rare in young pt (if does then Alpha triptan def) CXR show airway dz, not lung parencymal dz Lymphangioleiomyomatosis - rare cystic lung dz, aw PTX, predom young women, chylous pleural eff Tx: anti estrogen, sirolimus, lung tx

Answer 185

Hydralazine -isosorbide dinitrate alt for pt intolerant of ACEi 2/2 hyperkalmeia or kidney dz No norvasc - neurtral effect on outcome - only use for anginal/bp control if +meds (ACE/BB) maximized or failed, If intoleratnt of ACEi with hyperK or inc'd Cr don't use ARB instead - likely to do same thing Spironolactone only for NYHA III/IV HF inaddition to ACEi/BB - not usd when pt DOES NOT Have sev HF ALso has s/e of hyperK and kidney dysfxn

Answer 186

``` INR 2-3 warfarin x 3 months Triggered episode (long flight, ortho surgery, factor V ledien hetero) Factor V leiden doesn't inc risk of recurrent VTE - so no need to prolong therapy ``` No need for lifetime stardard warfarin - risks outweigh benefits

Answer 187

Peripheral smear shows clumping with CBC showing thrombocytopenia EDTA tube causes plt clumping Need heparin or citrate coated tube ITP - dx of exclusion - high dose steroids, if needs rapid rise temp - IVIG No need for plt tx

Answer 188

Assess pt immediate safety and develop safety plan provide validation, support emapathy Don't need to have pt leave abuser unless IMMINENT danger Don't confront abuser directly - may put victim in greater danger Don't need pscyh unless risk to harm self or others....

Answer 189

``` pre-excited afib NO p-waves, irregular rhythm Delta waves - WPW - with afib **DO not give AVN blocker - degenerate into VF with all conduction down non-decremental bypass tract Tx: procainamide or amiodarone or DCCV if hemodynamically unstable eventual EPS and RFA of pathway ``` Aflutter - atrial rate about 300, usually 2:1 block ventricular rate 150 MF Atach - usualy vrate 100 - 3 diff p wave morphologies Polymorphic VT - usually twisting of points -

Answer 190

limited (one hemithorax, hilar/media LAD within 1 radiation window) Need ppx rad of whole brain - if respond to initial tx Chemo+rad for SCLC No reason to bx residual mass No reason for chemo beyond 4-6 cycles Need ppx brain rad - don't just observe

Answer 191

B12 def - elev homocystein AND MMA +neuro deficits Folate def - elev HOMOcystein only NO neuro deficits exclude B12 def before supp folate - folate can correct anemia of B12 def but not neuro deficits

Answer 192

``` Ask about night lights rugs or thresholds between rooms clutter uneven lighting absent hand rails ``` Timed up and go test - if <14s = normal No reason for exc program if normal gait/motor exam No need for walker if TUG normal No need for opthal exam if vision 20/20

Answer 193

Indication for MV Repair 1. LVEF 40mm 3. Severe pulm HTN >50mm rest >60 exc 4. New onset afib Don't tx with bosentan- not primary pulm HTN is 2/2 MR No role for ACE in asx pt for afterload reduction - only if acute decompensation then IV acei Don't replace MV if possible - do repair - no long term A/C

Answer 194

Sx: dypnea, peripheral edema, wt gain, fever, hypotension, AKI, pleural/pericardial eff, 1-3 wks into therapy Mech - release of cytokines from differentiating promyelocytes -> capillary leak Tx: dexamethasone therapy NOt Transf rel lung injury - fever, dyspnea, pulm infiltrates seen but NO wt gain, peripheral edema, AKI - should be in last 48 hrs Not CHF - doesn't explain fever, AKI, does not have JVD, and S3 gallop Not PNA - hard to know - may need to treat both...

Answer 195

``` Stage III - invading pericolic fat +3 LN FOLFOX - 5FU, leukovoran, oxiplatin Surgery then folfox better with oxiplatin ``` No radiation as hard to localize therapy witout bowel s/e (small bowel rad tox) Radition+chemo for RECTAL CA as can be isolated from small bowel pre-op Anal ca - chemo+rad only...

Answer 196

Observation | Low risk stage I prosate Ca with Gleason 10 years

Answer 197

suspicious finding on PE for breast CA Core needle biopsy mass No need for breast MRI - need tissue dx - can feel mass No Breast US - need tissue dx Need dx - don't just reassure

Answer 198

Dx: pt with malodorous vag d/c - burning and itchign 1. homogenuous thin d/c 2. clue cells on saline microscopy 3. pH vag fluid >4.5 4. whiff +/fishy odor - no hyphae or pseduohypahe tx: flagyl x 7 days, vaginal flagyl gel, vaginal clinda cream if flgayl avoid etoh (disulfuram like rxn) Vulvovaginal candidiasis - yeah and hyphae on KOH, - oral fluconazole single dose or topical clotrimazole Trichomoniasis - multiple sexual parters - malodoorous d/c with vulvar itching, burning, postcoital bleeding - elev vaginal pH - whiff + but NO CLUE CELLS tx: Single 2g dose flagyl

Answer 199

obesity, large neck cirucm, daytime fatigue - r/o OSA Sleep study snoring, gasping, breathing problems ddx - OSA, restless leg syndrome, periodic limb movement d/o) Sleep latency - t give sleeping pills until 2ndary causes ruled out Iron studies - if suspicion of restelss leg syndroem - unpleasant sensatio nin legs better with moving - kicks partner in bed, can have associated IDA, ESRD

Answer 200

Uncomplicated back pain Tx: analgesics and mobilization as tolerated non-opiod No CBC/ESR (inflamm spondylitis, infxn, malig) as no signs of systemic infection No episudral steroids - only with chronic pain Lumbar imaging only if acutely progressing sx - evidence of cord comperession (saddle anesthesia, dec'd rectal tone) or susptected infxn/malignnacy Lumbar spine xray - r/o malig or fx - no need if no malig suspsected MRI not needed even if showed herniation and root compression management would be same

Answer 201

Add in line humidfied heated air to relieve rhinitis NO need for modafinil waking agent yet - need to optimize CPAP Dont use oxymetazoline spray - will have rebound nasal congestion after d/c use Nasal surgery only for mild OSA with siginficant nasal obstruction ie nasal polyps, septal dev, tonsillar enlargement

Answer 202

Decrease BP <70 (CAD+DM) | Tx of TGA only if non-HDL elevated LDL Goal + 30

Answer 203

h/o hodkins with radiation tx many years ago worsening DOE (could be CAD or diastolic dysfxn, radiation valve dz, restrictive CM - pericardial constrictive pericarditis) For CAD r/o - EKG excercise stress - usually pLAD given anterior location No reason for cardiac CT - no kusmall's sign no sign of costrictive pericradits (inc in JVP with inspiration), no RHF, normal CVP, normal IVC with insp collapse NO reason for RHC - can dx pericardial constriction - equalization of diastolic pressures - dip and plateu, steep y descent No TEE - if no pathologic regurg on TTE no need

Answer 204

``` Baloon mitral valvuloplasty Progressive SOB - symptomatic Severe MS - gradietn >10 LAE minimal leaflet Ca and thickening Min MR, minimal subvalvular thickening ``` Can't use BB with low HR (used to inc diastolic filling time) MV replacement in pt with MS and mod to sev MR, or undergoing other cardiac surgery anyway or unsuccessful percutantous result Open commisurtomy - r/o surgery only if anatomy not favorable for BAV

Answer 205

r/o PTX with chest xray Sudden onset pleuritic CP, dyspnea COPD, sudden SOB with hyperresonance, dec'd Breath sounds, dec'd chest wall movmeent CHest CT only if xray equivocal No need for echo or EKG first - r/o PTX first

Answer 206

therapeutic dose LMWH -> coumadin need A/C to avoid involvment of deep venous system Recurrent risk factors (catheters, thrombophilia, CA) Potential to -> DVT-> PE Serious conisderation of A/C with extensive thormbophelbits (traditionally low risk just compression stockings/NSAIDs) Don't just continue ibuprophen - unlikely to provent progressive thormbosis IVC filter not needed if no A/C contraindication No vein ligation if close to inovling deep veins (only for inovlvment of a specific target vessel)

Answer 207

Elderly pt depression pw somatic and vegetative sx not dysphoria -> screen for depression PHQ-9 10 or greater is cutoff Risk factors - livining in institution, chornic illness, recent death of spouse, Assesses anhedonia, deperssed mood, sleeping difficulty, changes in appetitie, feling of guilt, worthlessness, dec'd energy, suicidal ideation, concnetration issues Dix Halpike maneuver - dx BPPV - check for vertigo or nystagmus MMSE - cognition testing - only test if some reason to suspect dementia or MCI TUG - risk for falls >14 s

Answer 208

hypoxia, dypnea, fever, hypotension within hours of getting blood products - resembles non-cardiac pulm edema - pulm infiltrates on CXR Etio - antileukocyte Ab in donor blood -> sequester in lung Tx: supportive Acute hemolytic transfusion reaction - clerical error in ABO compatilibity - very early rxn - hypotension, DIC, NOT PRIMARILY HYPOXIA Febrile nonhemolytic transfusion rxn - during tx - > Fevers - NOT hypoxia or pulm infiltreates Tranfusion associated circulatory overload - usually with multiple units of blood products - more likley with underlying cardiac dz

Answer 209

Stage IA - observation after surgery with neg margins - no need for adjuvant chemo TAH+ salphooophorectomy b/l, omenectomy, pelvic washings for cytology Adjuvant chemo for high stage - IC or greater = paclitaxel/carboplatin No role for "second look surgery" IP/IV chemo - stage II/III ovarian CA - not for early stage

Answer 210

Ongoing use of topical nasal vasoconstrictors - continued use with diminishign returns - withdrwawal cuases SEVERE congestion Tx: withdraw use - use nasal corticosteroid or nasal saline spray to mitigate withdrawal sx Chronic rhinosinusitis - mucopurulent drainage, facial pain/pressure typical of sinusitis Chronic nonallergic (vasomotor) rhinitis - one typical sx of rhinitis (sneezing, rhinorrhea, nasal conj, postnasal drainage), in absense of specific etiology - can't dx this until rhnitis medicamentosa r/o Granulomatosis with polyangiitis - necrotizing vasculitis - affects upper resp tract and kidneys - 70% with sinusitis - pulm manifestations including cough, hemoptysis, pleurisy

Answer 211

W>M young pts Anterior knee pain worse with sitting and going UP AND DOWN stairs Patellofem compression test- knee extension, push patella both med and lat with pain tx: conservative tx OA Knee - Age>50, stiffness <30 min, crepitius, bone tendernes/enlargement, no warmth Pes Anserine bursitis - pain anteromedial aspecto of prox tibia, swelling at insertion of hamstring medial - Pre patellar bursitis - caused by recurrent trauma - kneelinig, infection or gout, pain located anteriorly - tnederness/swelling in lower pole of patella to palpation with erythema

Answer 212

Hereditary spherocytosis - splenomegaly, fhx anemia/leg ulcers/gallstones Smear: spheroctyes sx: asx to severe hemolysis/fatigue Episodes of severe anemia from parvovirus B19 infection - transient aplastic crisis Dx: elev bili, LDH, high retic (5-20%), +osmotic fragility test Alpha thal (a/-, a/- or a/a, -/-) mild anemia microcytosis, hypochromia, target cells (HALT) NORMAL Hg ELECTROPHRESIS (B thal is abn) G6PD - AA men - smear normal between crisises - but bite cells during acute hemolytic episode - NO SPHEROCYTES Warm autoimmune hemolytic anemia - does have spherocytes but would have +direct coombs and no fhx of anemia/gallstones Sickle cell anemia (Hb SS) - mod to sev anemia with pain crisies - normocytic, sickle cells

Answer 213

Not conductive - better air conduction than bone DDX: infection, neoplasm, truma, autoimmune, vascular events, ototoxic drugs Needs urgent ENT eval - oral or intratypmanic corticosteroid tx Otic herpes zoster (ramsey hunt syndrome) - herpetic lesionis in ear canal - and ipsilateral facial palsy - tx: acyclovir Acute otitis externa - neomycin, polymxyin hydrocortisone drops - otalgia, otorrhea tenderness with tragal or pinna tugging Triethanolamine ear drops - cerumen removal - cuases conductive hearing loss not sensoneural - no tinnitis

Answer 214

L nephrectomy Pain, mass, hematuria, - chest imaging c/w mets Survival improved with resection of primary tumor (ONLY IN KIDNEY CA does it improve outcomes and not just reduce local sx) - only pt eligible for immuotx then tx with IFN alpha CT lung bx only after primary tumor resected Bx not recommended - doesn't change need for resection - neg bx would be viewed as false neg Systemic tx - sunutieb, sorafenib, - may be helpful in RCC but NOT cytotoxic chemo...

Answer 215

V/Q scan to dx PE given inc'd Cr Lenoliamide and dexamethoasone -> high risk of VTE (also high risk with anthracycline, cytotoxic agents) Other risk factors - h/o VTE, CV catheter, recent surgery, immobilizattion, hypervisc from paraproteins from MM, DOn't use CTA chest with CKD CT without contrast wouldn't see PE without fever, crackles on exam PNA less likely

Answer 216

Pt older than 40 with hematochezia should undergo colonoscopy or sigmoidoscopy r/o colonic neoplasm as source of bleeding In 50 then colonoscopy (not sigmoidoscopy) If colon CA excluded - then tx hemorrhoids conservatively - only do banding if conservative tx fails Fiber supp only is inappropriate need to w/u bleed in >40yo pt Home FOBT would likely be + with bleeding hemorrhoids - either way will need scope

Answer 217

Pt needs AAA Abd US screening - 65-75yo MAN with smoking history (100 cigarettes or greater) No CAC - not recommended for asx patients No CXR or Chest CT (low dose) - despite being former smoker Lipid profile women Men >35yo or women >20yo who are at inc'd risk for CVD then q5years if low risk

Answer 218

Single or few areas of cognitive trouble MMSE 24 or 25 Dementia clues - language, memory, apraxia (problems with dressing unrelated to motor fxn), impaired executive fxn, Alzheimers - less likely if only one or two domains of problems(no issue with ADL, language) - MMSE 19-24=mild dementia - 10-19=moderate Pseduodementia - cognitive impairment 2/2 depression - tx will improve cognition Vascular dementia - unlikely with MMSE 25 - vascular dementia would not just have memory defect in isolation - would affect other cognitive and neurologic fxning

Answer 219

Dull aching groin pain - indolent Risk factors etoh abuse, chronic steroids Severe pain in early stages with bone death Limited ROM of hip on exam Early stage radiolography normal Patchy areas of lucency/sclerosis may be seen - MRI most senstive and postive earliest OA of hip - h/o pain in groin and medial thigh - worse with activity better with rest, no period of SEVERE PAIN Radiographs with joint space narrowing and osteophytes subchondral sclerosis NEvere have normal radiograph Septic arthritsi - acute onset with fevers, limited ROM L1 radiculopathy - pain, paresthesia, sensory loss in groin

Answer 220

PT/gait evaluation effective intervention to reduce fall risk in elderly w/u of dizziness usually unfruitful - Could be 2/2 meds, sensory impairment, weakenss, neuropathy, anxiety, deconditioning, deperession, postural hypotension Also needs eval for visioin/hearing aids Don't change lantaprolst to a BB(timolol) inc r/o falls/dizziness Don't change ACE-> arb won't do anything Vestibular rehab only if BPPV

Answer 221

Patient with average risk prostate CA - DRE+PSA check q6-12 months Clincial stage IIa with good response to radiation Androgen deprivation tx - high risk localized dz - or loaclly advanced dz - usually start before radiation then continue after Chemotx - docetaxel - for hormone refractice met prostate CA - - no benefit in pt without mets No benefit with serial CT/bone scans

Answer 222

Malignant pleural eff = stage4 = uncurable Tx: palliative systemic chemotherapy goals syptom palliation/prolongation of survival Combo chem/rad - unresectable stage III - where tumor and LN can be encompassed in radiation field No radiation as first line tx (only for palliation with SVC syndrome, obstructive pneumonitis, brain mets, SC compression, bone mets) No surgery as pt already is stage IV - would not improve survival and would inc morbidity

Answer 223

Fiberoptic endoscopy of oropharynx with bx - dx SCC of head and neck can occur in pt without risk factors - (EBV or HPV?) Painless mass, mucosal ulcer, localized pain of mouth, teeth, throat, ear, odynophagia, diplopia, loss of vision, hearing loss, sinusitis Don't do excisional bx - would compromise tissue planes for surgical approach for cancer later - use FNA instead MRI after fiberoptic endoscopy for staging Also PET/CT after endscopy for staging

Answer 224

h/o smoking, elderly pt - painless gross hematuria Dx: Cystoscopy Need to r/o bladder CA can use cytology in conjunction but not instead of cystoscopy (to detect upper GU tract malignancies no seen by cystoscopy) No PSA - pt with prostate CA can have hestiancy, decreased stream, nocturia but not bleeding usually No UCtx as pt not with elevated leukocytes in u/a or urinary sx

Answer 225

Recurrent episodes of binge eating with copenstaory purging to prevent weight gain vomiting, exercise, laxatives Purging subtype - metabolic abn (hypokalemia, hypoMg, met alkalosis) At least 2/wk x 3 months Self perception influenced by body weight and shape NORMAL WEIGHT Dental caries, enlaarged salivary glands scaring on dorsum of hands Regular menses Anorexia nervosa - LOW BODY WEIGHT buliemia nervosa Binge eating d/o - no assoicated compensatory behavior Night eating syndrome - excessive eating at night, difficulty sleeping, morning anorexia - prevalaent in obese pts

Answer 226

Refer for genetic counseling only referred for genetic testing with counseling potential harms of genetic testing 1. pt has personal or fhx of genetic condition 2. genetic test that can be adequately interpreted 3. test results will aid in med/surgical management Brain MRI not useful in asx patient with huntingtons Don't just reassure pt - no idea when symptoms might manifest

Answer 227

In first month after hospital dc following VTE - pt should be bridged with LMWH if subtherapeutic and warfarin increased check INR in 3-5 days Recurrence risk is 40% so bridging is needed Chronic warfarin users with <0.5 off therapeutic level do not need bridging

Answer 228

6 month h/o pelvic pain, urinary freq, painful ejaculation, and on multiple UTI abx courses without resolution Need 1 month prolonged course of abx (cipro) Acute bacterial prostatitis (cat I) - 1 week bactrim Category III prostatitis - chronic abacterial prostatis/chornic pelvic pain syndrome - non-infectous - no abx needed Need CBT + empathetic supportive care Finasteroide 5 alpha red inhib - used in BPH - reduces prostate volume - not used for bacterial prostatitis

Answer 229

macrovalocytes and hyperseg neutrophils on smear ineffective hematopoesis -> hemolysis -> elev LDH/bili, icterus, fatigue, low retic count glossitis, wt loss, jaundice, yellow skin neurologic sx - loss of position sense, vibratory sense - spastic ataxia Warm autoimmune hemolytic anemia insidious anemia, jaundice smear: spherocytes (erythrocytes lost central palor) Direct coombs - postiive for IgG, neg for complememnt tx: steroids -> splenectomy Paroxysmal cold hemoglobinuria Rare hemolysis in adults IgG Ab bind to erythrocytes in cold -> COMPLEMENT FIXATION - smear microspherocytes Tx: self limited Hereditary spherocytosis - inherited RBC membrane defect - spheroctes on smear, inc'd gallstones - splenomegaly

Answer 230

Microcytic anemia, target cells, mild anemia, hypochromia abn or slightly inc'd erythrocyte count MCV/erythrocyte count 13 (MCV/erythrocyte count) Sideroblastic anemia - decreased erythrocyte count - ineffective hematopoesis basophillic stippling - stain + for iron hypo or normochromic, macrocytic

Answer 231

pt with fibromyalgia previously well controlled now worsened recently Evaluate psychosocial stressors ie intimate partner violence No reason for further dx testing or imaging first in absense of physical findings No NSAIDS for fibromyalgia/neuropathic pain (ok for MSK pain, inflamm arthrits, RA) GI and cardiac tox Opiod therapy - don't give for chronic pain sydorem -> dependence, lack of effect

Answer 232

Don't prescribe abx for adults with otitis media Viral URI dull typanic memb with small middle ear effusion otitis media vs viral uri without otitis media Just observe, no tx IF do give abx -> amoxiciinllin (erythromycin if PCN allergic) No ENT referral - pt just has URI

Answer 233

Hormone + (estrog/prog) Tx with aromatase inhib if POST menopausal -> Anastrozole x 5 years 20% risk of recurrence without therapy s/e arthralgia, hot flushes, osteopenia/porosis Tamoxifen inc's r/o endometrial CA Trastuzumab - for HER2neu+ cancers

Answer 234

1mm deep, 2cm margin for resection +LN need LN dissection No radiation therapy indicated No adj interferon in <0.75mm deep

Answer 235

Admit to CCU Pt with anterolat ST dep with substernal CP, age, HTN, HLD -> intermediate risk Don't stress pt with active ACS (could worsen ischemia and induce arrythmia) - needs tx with ASA, plavix, heparin gtt, statin, BB +- ACEi CTPA - only if high prob of PE NSAIDS - acute pericarditis or MSK pain - not pleurtic in nature or reproducible, no EKG changes c/w pericarditis (diffuse ST elev/PR dep) - no EKG change with MSK pain

Answer 236

Gleason 8 to 10 cancer beyond prostate PSA >20 NO SURGERY Androgen deprivation therapy (GnRH agonist) and radiation ADT also used for metastatic dz or those with rising PSA after initial definitive tx Brachytherapy (seeds) - low or avg risk CA Gleason <20 Radiation tx - Low or avg risk

Answer 237

respond with empathy, cmpassion Assess adequacy of current therapy Don't seek counsel don't just refuse request - talk to pt Don't just write a sedative rx

Answer 238

Washed cells - minizes r/o anaphylaxis in pt with IgA deficiency (and therefore likely IgA Ab) -also prone to GI infections (partuclary giardia), inc'd r/o autoimmune d/o RA, SLE, (or blood products from IgA def donor) Gamma radiated cells - eliminates leukocytes and reduces r/o graft vs host dz Leukoreduced blood - reduced febrile non-hemolytic transfusion reactions, CMV transmission, alloimmunization Phenotypically matched blood - high risk for alloimmuniz (ABO, Rh, Kell (c, e, k) Ags) - no change in anaphylaxis risk)

Answer 239

Pt with chronic hemolytic anemia (ie sickle cell dz) Already have low erythrocyte survival Parvo B19 decreases retic/prodxn suppresion Recent illess - fever arthralgia Dx: IgM or PCR Parvovirus B19 Hyperhemolytic crisis - sudden worsening of sickle cell anemia with reticulocytosis Megaloblastic crisis - inc'd demand during grwoth for folate, preg pts, chronic hemolysis - unlikley to be acute and unlikley if pt takes folate Splenic sequestration crisis - splenic pooling of rbcs, drop in Hg, reticulocytosis, splenomegaly, LUQ pain

Answer 240

NSAIDs, tylenol, ASA for mild pain (1-3/10) Mod pain - opiods/non-opiods Severe pain - opiods Adjunctive therapy - antidep, steroids, muscle relaxants, anticonvulsants (neurontin) - better for neuropathic pain Don't use meperidine - lowers sz thereshold, varable oral availabliity Don't give morphine IM - unreliable absorbptio nand don't give opiod b4 NSAID with mild pain

Answer 241

Pt doesn't want to take pill -but has high risk behavior Need condoms + dept form of birth control Don't use methyprog depot injection or vag ring along as does not protect vs STIs Don't use condoms + the pill as she isn't reliable taking pill

Answer 242

Trial of NSAIDs inhibits inflammation, vasoconsriction, uterine ischemia Next step combo OCP Depot methprog - don't use for younger pt - dec's bone density - 2/2 long term estrog def No need for hormonal testing or pelvic imaging if no pelvic pain, sig bleeding abn

Answer 243

Surgery with adjuvant chemo Solid tumor without mediastinal or local LN involvment - stage IB (tumor >3cm) Chemo+rad - locally advanced tumors - Stage III - mediastinal LN involvment Radiation tx - never used as sole therapy in lung CA Early stage too much morbidity, late stage not enough, need chemo Systemic chemo - palliative care in pt with advanced dz only NOT in early stage dz

Answer 244

Prompt plasmapheresis prodxn monoclonal IgM Ab hypervisc syndroem - LAD, SM, dizziness, blurry vision, dilatd tortuous retinal vessesls - epistaxis from qualitatative plt dysfxn from IgM excess No UTI so no cipro No PRBC or diuresis - may exacerbate hypervisc syndrome Not HTN encep - changes in level of concousness, focal neuro def, visual field def - retinal hemm, exud, papilledema

Answer 245

Interval on multidose vaccines are MINIMUM not maximum Just need to complete series if was prev lost to f/u after first shot in multishot hep B series Only need to measure vacc response with Hep B Ab content in high risk ppl ie HC workers, HD patients, pt exposed to Hep B Pt with Hep C is at increased risk if exposed to Hep B so needs vaccines - shouldnt just do nothing

Answer 246

insidious onset lasts hours to weeks sharp, localized worse with turning, deep breathing, arm movement CV exam normal Acute pericarditis CP - pleuritic, worse with breathing, recumbant position, friction rub, h/o recent viral infxn, MI, trauma, malignancy meds, CTD, uremia Aortic dissection - tearing/ripping pain, rad to back , h/o HTN, asym pulses, U/A - rad to arms, exertional, better with rest, diaphoresis, n/v, pressure

Answer 247

Pt chooses agenda assess which lifestyle changes are important to pt Don't tetll to lose weight or quit smoking Most effective to figure out what pt considers most imporant to change then give advice on that pt likely to be most motivated to do that...

Answer 248

at level of elbow Pain occurs with flexion of elbow NO PAIN at medial epicondyl parasthesia palmar and dorsal surfaces of arm cubital tunnel - near surface of medial elbow sustained pressure or minor trauma on nerve maneuvers that strech or compress nerve elicit sx If entraped at wrist - palmar only parasthesia Lateral epicondylitis - tennis elbow - pain in lateral elbow radiating down prox forearm to DORSAL hand, tenderness to palpation at lateral epicondyl Pain with forced EXTENSION of wrist Medial epicondylitis - golfers elbow - medial elbow pain-> prox forearm, pain repordced by forced FLEXION of wrist tenderness to palp of med elbow Olecranon bursitis - pain in POSTERIOR elbow - swelling of bursar sac - ROM NOT LIMITED...

Answer 249

MRI shoulder Difficulty aBducting left arm +Drop arm test Don't just give NSAIDs or PT - need accurate dx first to r/o need for surgery Steroid injction for rotator cuff tendonitis or impingement syndrome but not for tear

Answer 250

COunsel sleep hygene behav or environmental factors coudl be temp noise level, bed comfort Etoh can cause insomnia but not likely in small quanitites only on weekends Only goto pharm therapy if nonpharm fails 1st line non benzo zolpidem - don't affect sleep archieture 2nd line benzo - short term only

Answer 251

``` painless progressive vision loss distortion of vision central vision loss most prominent Drusen - amorphous depsoits behind retina like yellow spots all round eye Smoking= etio usually ``` Catarct - opacification of lens - vision loss progressive, worse in BRIGHT LIGHT or at night Primary open angle glaucoma - inc'd IOP - -> progressive optic neuropathy - Painless gradual loss of PERIPHERAL vision later stages central loss inc'd cup to disc ratio Retinal detachment - seperation of neurosensory layer from choroid beneath - Trauma or spontaneous Sx: diminshed vision, floaters, photopsia wavy vision, LOSS OF CENTRAL VISION Fundoscopy: folds of retinal tear

Answer 252

Likley OA given age Pain to palpation of acromioclavicular joint Pain occurs with shoulder ADduction and ABduction above 120 deg Trauma (yonger pt), OA (older pt) Absense of pain on palpation good NPV Palpable osteophytes cross arm test + Adhesive capsulitis - thickening of capusule around glenohumoral joint Pain slow onset, near insertion of deltoid Pain on lying on affect side Loss of both active and passive ROM in ALL PLANES Rotator cuff tear - suprspinatous wk, weakness ext rotation, evidence impingment, +drop arm test Rotator cuff TENDONITIS - pain 60-120 deg aBduction can't int/ext rotate arm Neer+ - arm extended 180deg (near ear) Hawkins + like hawk trainer starting postioin - inter/ext rotate arm - pain = psoitive - shows possible impingment of tendons between muscles

Answer 253

Pelvic floor muscle training loss of urine while cough, sneeze, activity, -> sphincter incontience PE - weakened anterior/posterior vaginal wall (cystoceole, rectocoele) (Kegels) Prompted voiding - significant cognitive or mobility issues (can't make it to bathroom when need to go) Sling procedure - (pubovaginal) - mod to severe stress incontincne - refractor to kegels, pharm thereapy Tolterodine - antimuscularinc anticholinergic For urge incontinence - would have sense of urgency prior to incontinece (detrusor overactivity) - also timed voiding helps

Answer 254

Endoscopic sinus surgery - low risk (or catarct, breast, superificial, ambulatory surgery) No need for preop cardiac testing unless high risk conditions ie unstable angina, decomp HF, significant arrythmia, , severe valvular dz If currently on BB keep on BB Revised Cardiac Risk index - only if high risk will need preop testing - Pt with low or unknown ET and undergoing int or high risk surgery - need preop cardiac testing No need for cath - try for non-inv testing TESTING ONLY DONE IF WILL AFFECT MANAGEMENT IE WILL SEND PT FOR CATH TO GET A URGNETLY NEEDED STENT (won't just benefit from med therapy)

Answer 255

Childbearing age - check preg test result WILL CHANGE management (or if will impact periop care) No sign/sx pulm dz so no CXR needed No h/o, fhx bleeding, liver dz, etoh sig use, A/C use, - so no coags needed No need for EKG - no sig/sx cardiac dz, no risk factors - only get in pt where silent or prev unrecognized MI possible...

Answer 256

Elective hip surgery - go with non-operative managemnt pt too high risk Child Class C - avoid surgery r/o hep failure, bleeding, infection, adverse drug rxn, poor wound healing, CTP based on ascites, encep, bili, alb, INR No role for corticosteroids - only for acute etoh hep (leuko, RUQ pain, jaundice, Hepmegaly) Cirrhotics - predisp to bleeding from quant and qual plt issues and def of liver produced clotting factosr Vit K does't improve cirrhotic bleeding risks - INR elevation not usually 2/2 vit K def in cirrhotics

Answer 257

No further testing Only if low ET or multiple risk factors Need Mets >=4 RCRI - h/o IHDz, copensated or prior chornic HF, DM needing insulin, CKD, h/o CVA No RCRI factosr so no need for testing even though poor ET No need for cath CT coronary not studied for preop risk assessment (coronary) No need for preop stress in pt with RCRI 0 or 1 (ie low risk patient despite comorbidieies)

Answer 258

septic thrombosis of jugular vein CT neck with contrast for dx fever, inc WBC, pharyngitis, sore throat, unilateral neck tenderness, multiple densities on chest radiograph - septic emboli** Tx: IV abx (zosyn, ampiciliin-sulbactam) No need for CT chest Soft tissue xray of neck won't see jugular thrombosis Echo could r/o R endocarditis as source but unlikely in current clinical scenario

Answer 259

Initial therapy NSAIDS or tylenol Next: Arch support (pt with pes planus - flat foot) - flat foot redistructes forces and cuases pain - may take months for recovery Don't inject steroids until arch support fails (only short term solution - steroids) NO role for extracorporea shock therapy Surgery only for refractive plantar fasciitis

Answer 260

TOPICAL clomitrazole (not fluconazole) VVC - itching, discomfort, thick white d/c cottage cheese, vulvar edema/erythema KOH - hypae/pseudohyhae Complicated - severe sx (extensive vulvar erutyma, edema, excoration, fissues), DM, immunosupp, PREGNANCY, multiple recurrences recurrent=>4 / yr boric acid, voriconazole (non-imidazole)

Answer 261

empiric PPI therapy 8-12 wks for GERD related cough (first lifestyle mod) No abx if no evidence of infxn (upper airway cough syndrome - cobblstoning, post nasal d/c - NO NEED for antihist/decong until PPI deemed ineffective Cough variant asthma - no need for inhaler if pt has reasonable suspicion for GERD as of now

Answer 262

``` Predominantly myopic patients Floaters squiggly lines sudden peripheral visual defect black curtain across visual field flashes of light Tx: Surgery - emergent opthal referral ``` Central retinal artery occlusion - painless loss of vision, elderly, cherry red fovea (accentualted by pale background from dec'd bloodlflwo) - pale fundus - usually elderly Central retinal vein occlusion - monocular vision loss, cloudiness of vision, cotton wool spot (blood and thunder), congested tortuous veins - retinal hemorrhages Ocular migraine - with or w/o h/a - foaters/squiggl lilnes - NO VISUAL field defect or tear in retina/folding Temporal arteritis - h/a, no preceeding floater/squiggly lines

Answer 263

CBT + SSRI (fluoxetine) Recurrent obs/comp occupy at least 1 hr daily or interferenign with social fxn/work fxn Obsession - persistetn ideas, thoughts, imopulses images that felt to be intrusive or cause stress/axiety (fear of germs) Compulsions - reeptive behaviors that dec anxiety related to obsessions (Hand washing) Haldol - combi with SSRI if alone not ok No benzos Quietapien - 2nd line if SSRI tx fails

Answer 264

elderly woman brief prodrome with palpitations LIKELY CARDIAC arrythmia Aortic stensosi can cause synope but usually with exertion... Not myoc ischem - usually have ischemic sx, Not TIA - usually shoudl have focal neuro sx/findings

Answer 265

``` Palpable breast mass should be evaluated till dx or resolution Needs US likley fibroadenoma or benign cyst (soft, discrete round mobile mass - ) US will give cystic vs solid If cystic - need needle aspiration and analysis If solid - FNA bx needed Still needs to be followed if beningn ``` Imaging should proceed bx (core needle) Don't get mammo in young woman with dense breasts Don't wait 6 months and observe need to evaluate now...