EOR practice exam Flashcards
An HIV-positive patient presents with worsening dementia, fever, HA, and right hemiparesis. CT of the brain reveals six lesions throughout the brain that show ring enhancement and surrounding edema. What is the treatment of choice for this condition?
Sulfadiazine and pyrimethamine
Toxoplasmosis is commonly noted in HIV-positive patients and presents with multiple ring-enhancing lesions. Sulfadiazene is a sulfa Abx and pyrimethamine is an anti-parasite.
What is toxoplasmosis?
parasitic protozoa
- Triad of: encephalitis + chorioretinitis + intracranial calcifications
in AIDS patients with CD4 < 100
- pregnant female with exposure to cat feces (reason we tell pregnant mothers not to change cat litter)
- Congenital toxoplasmosis is part of ToRCH syndrome (infection of developing fetus or newborn by any of a group of infections: (T)oxoplasmosis, (o)ther agents, (R)ubella, (C)MV, and (H)erpes Simplex
Diagnosis of Toxoplasmosis
CT of the brain shows ring-enhancing lesions
enzyme linked immunoassay (ELISA) positive for anti-toxoplasma IgG and IgM
A 52 yo female comes to the office because of black stools for the past 3 days. She is afebrile and has no pertinent PE abnormalities. What is the most appropriate initial diagnostic study?
stool for occult blood
(Melena suggests a source of bleeding proximal to the ligament of Treitz, not a lower GI bleed; sigmoidoscopy is used to evaluate only lower GI bleeds)
What is an example of pre-renal azotemia?
Renal hypoperfesuion
is the cause of prerenal azotemia which may be rapidly reversible when renal blood flow and glomerular ultrafiltration pressure are restored
azotemia (azo, “nitrogen” + -emia, “blood condition” ) is characterized by abnormally high levels of nitrogen-containing compounds (urea, creatinine, various body waste compounds)
a 65-year old patient with steroid-dependednt COPD presents with a HA that has been increasing in severity over the past week, accompanied by nausea and vomiting. He denies fever but has had photophobia and a stiff neck. What is the most likely diagnosis?
Cryptococcosis
Cryptococcosis is an opportunistic fungal infection that affects immunocompromised patients, including those with HIV, chronic steroid use, organ transplants, diabetes mellitus, and chronic renal or liver disease. The most common clinical presentation is that of meningitis; fever is present in only about half of patients.
What is cryptococcosis?
caused by fungus cryptococcus neoformans, common in AIDS and immunocompromised patients. It is considered an AIDS defining illness. Budding yeast found in soil contaminated with pigeon/bird droppings.
transmitted through inhalation and causes illness in patients with cellular immune deficiency such as HIV, cancer, or long-term corticosteroid therapy
- meningocephalitis: most common cause of fungal meningitis (may present with AMS, HA, or meningismus)
- Pneumonia: cough with little sputum and pleuritic chestpain
Diagnosis of Cryptococcosis
Diagnose with CSF and serum serology
- India ink stain may be positive
- CSF shows pleocytosis (predominantly lymphocytes), increased opening pressure, INCREASED protein, and DECREASED glucose
- Computed tomography (CT) or MRI is indicated if cryptococcoma is suspected
Treatment of Cryptococcosis
Amphotericin B + Flucytosine for 2 weeks
followed by Fluconazole for 10 weeks
Prophylaxis if CD4 < 100 with Fluconazole
Axial T2-weight MRI shows clustered hyperintensities in the left caudate; these are consistent with enlarged Virchow-Robin spaces caused by small cryptococcomas
What is a common symptom associated with laryngotracheobronchitis (viral croup)?
Barking cough
viral croup is characterized by a history of upper respiratory tract sx followed by onset of a barking cough and stridor
A 23 yo female with a history of asthma for the past 5 years presents with complaints of increasing SOB x 2 days. Her asthma has been well controlled until 2 days ago. Since yesterday, she has been using her albuterol inhaler q4 - 6hrs. She is normally very active, however yesterday did not complete her 30 minute exercise routine due to increased dyspnea. She denies any cough, fever, recent surgeries, or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. What initial diagnostic test is most appropriate prior to initiation of treatment?
peak flow
A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring the effectiveness of any treatment interventions.
a 3 yo boy is seen in the office with a 5-day history of fever, erythema, edema of hands and feet, a generalized rash over the body, bilateral conjunctival injections, fissuring and erythema of the lips, and cervical adenopathy. Antistreptolysin A (ASO) titer and throat culture are negative. The most serious systemic complication associated with this disorder is:
cardiac
The patient most likely has Kawasaki syndrome. The major complication with this disorder is coronary artery aneurysms, which are reported in up to 20% of affected children. The etiology of the disorder is uncertain, although a bacterial toxin with super antigen properties may be involved.
Kawaski Syndrome: fever > 5 days and 4 of the following
- conjunctivitis*
- rash*
- mucosal changes*
- edema of hands/feet*
- cervical adenopathy*
How do you diagnose and manage Kawasaki Syndrome?
Diagnosis
îESR/CRP, leukocytosis, reactive thrombocytosis (î platelets). Normochromic normocytic anemia. Sterile pyuria. Echo and angiography may be needed if heart involvement is suspected.
Management
INTRAVENOUS IMMUNE GLOBULIN + HIGH-DOSE ASPIRIN
- lowers fever, joint pain, & prevents coronary artery thrombosis/aneurysm*
- corticosteroids if refractory*
What are the five axes of DSM-IV?
Axis 1: describes clinical disorders and “other conditions which may be a focus of clinical attention”.
Axis 2: focuses on personality disorders and contains a rating scale for mental retardation.
Axis 3: labels any general medical conditions. (sometimes psychological problems can be the byproduct of an illness such as diabetes or heart disease)
Axis 4: specifies “psychosocial and environmental problems” such as poverty dysfunctional families, and other factors in the patient’s environment that might have some impact on the person’s ability to function
Axis 5: labeled the “Global Assessment of Functioning Scale”. it is an overall rating of person’s ability to cope with normal life. Rating goes from low scores such as 10 (“persistent danger of severely hurting self or others”) to 100 (“superior functioning in a wide range of activities”)
A 53 yo female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam, she is tachycardic and tachypneic with rales in the LLL. a CXR is unremarkable and an EKH reveals sinus tach. What is the most likely diagnosis?
Pulmonary Embolism
The patient’s risk factors for pulmonary embolism include advanced age, surgery, and prolonged bed rest. While the dx of PE is difficulty to make due to nonspecific clinical findings, the most common Sx include pleuritic CP, dyspnea associated with tachypnea. CXR and EKG are usually normal.
Hint: small atelactasis is commonly asymptomatic while large atelactasis may produce signs of dyspnea and cough. Exam revelas absence of breath sounds in the area involved and dullness to perussion. A CXR would reveal various findings dependent on the location of the atelactasis, but would NOT be normal.
Clinical Manifestations of Pulmonary Embolism
Dyspnea MC symptom & Tachypnea MC sign***
History:
classic triad, dyspnea + pleuritic chest pain + hemoptysis
Classic Presentation:
post-op patient with sudden onset tachypnea, tachycardia + cough or hemoptysis
Factor V Leiden is the MC predisposing condition
Physical Exam:
Pulmonary Exam is usually normal; may have rales or pleural friction rub
+ Homan’s sign (calf pain with dorsiflexion is a classic but nonspecific sign)
What is the best initial test for suspected PE?
Helical CT Scan (CT-PA)
PULMONARY ANGIOGRAPHY IS GOLD STANDARD DIAGNOSIS: ordered if HIGH SUSPICION & negative CT or VQ scans
others:
V/Q Scan: low probability only rules out PE in patients with low clinical suspicion
Doppler US: 70% of patients with with PE will be + for lower extremity DVT. can miss pelvic DVTs. serial US may be performed to increase diagnostic specificity.
Ancillary Evaluation Tests for PE
1. CXR: most often normal. A normal CXR in the setting of hypoxia is highly suspicious for PE
classic (but rare) signs on CXR:
Westermark’s Sign: avascular markings distal to the area of the embolus
Hamptons Hump: wedge-shaped infiltrate (represents infarction)
2. ECG: sinus tachycardia % nonspecific ST/T changes MC*
S1Q3T3 most specific for PE: wide deep S in lead I, isolated Q and T wave inversion in lead III
3. ABG: initially respiratory alkalosis (2ry to hyperventilation) ⇒ respiratory acidosis may occur with time. îA-a gradient
4. D-dimer: helpful ONLY if negative & low suspicion for PE (high sensitivity, poor specificity)
Management of Pulmonary Embolism
-
Anticoagulation
* Low Molecular Weight Heparin (LMWH) or Unfractionated Heparin (UFH)
need to monitor PTT with UFH but not needed with LMWH
Higher risk of Heparin Induced Thrombocytopenia (HIT) with UFH
- Warfarin (COUMADIN) for at least 3 months–should be overlapped with Heparing for at least 5 days AND INR 2.0 to 3.0 at least 24 hours
- Novel Anticoags–LMWH followed by Dabigatran (direct thrombin inhibitor) or Edoxaban (Factor Xa inhibitor) can be used instead of Warfarin and may be preferred
2. IVC FILTER: hemodynamically stable patients in whom anticoagulation is contraindicated or is unsuccessful*
3. THROMBOLYSIS OF CLOT: streptokinase, urokinase, alteplase
IND: massive PE, hemodynamically unstable PE. resolves emboli within 24 hours. usually preferred over embolectomy
CI: CVA or internal bleed w/i 2 months
4. THROMBECTOMY/EMBOLECTOMY: unstable/massive PE if thrombolysis is contraindicated or ineffective
Pulmonary Embolism Prophylaxis
the single most important step in managing PE. Prophylaxis is warrranted preoperatively in patients undergoing surgery with prolonged immobilization, pregnant women, history of prior DVT/PE.
Early Ambulation: low risk, minor procedures in patients < 40 yo
Elastic stockings/pneumatic compression devices/venodyne boots: moderate risk
Low Molecular Weight Heparin: patients undergoing orthopedic or neurosurgery, trauma
PERC Criteria for Pulmonary Embolism
(Pulmonary Embolism Rule Out Criteria)
If all the following is negative, you can effectively rule out PE if there is low suspicion for PE:
Age < 50 yo
Pulse < 100 bpm
O2 Sat > 95%
No prior PE
No recent trauma or surgery
No hemoptysis
No use of exogenous estrogen
No unilateral leg swelling
34 yo female with h/o asthma presents with complaints of increasing sthma attcks. patient states she has been well controlled on abuterol until one month ago. since that time she has had to use her inhaler 3 - 4 times a week and also has had increasing nighttime use averaging about 3 episodes in the past month. Spirometry reveals > 85% predicted.
What is the most appropriate intervention at this time?
the patient has progressed to mild persistent asthma. in addition to her beta-2-agonist (albuterol), she should be started on an anti-inflammatory agent. Inhaled Corticosteroids (ICS) such as beclamethasone are preferred for long-term control.
definition of intermittent, mild persistent, moderate persistent, and severe persistent asthma
In adults and IV drug abusers, which bone is most commonly affected with acute osteomyelitis?
vertebral spine
bones of the vertebral spine are MC affected in a patient with osteomylitis. organisms reach the well-perfused vertebral body via spinal arteries and quickly spread from the end plate into the disk space and then to the adjacent vertebral body. the infection may originate in the urinary tract and IV drug use carries an increased risk of spinal infection
a 43 yo asymptomatic diabetic female is found to have an elevated total calcum level of 12.4 mg/dL. Which test must be assessed in order to evaluate this lab abnormality?
serum albumin
since approximately 50% of calcium is protein bound, total calcium levels should be i_nterpreted relative to albumin levels_
Which condition would cause a positive Kussmaul’s sign on PE?
constrictive pericarditis
Kussmaul sign is a paradoxical rise in jugular venous pressure (JVP) on inspiration, or a failure in the appropriate fall of the JVP with inspiration. It can be seen in some forms of heart disease and is usually indicative of limited right ventricular filling due to right heart dysfunction.
frequent finding in patients with constrictive pericarditis or right ventricular infarction
What are the common clinical manifestations of constrictive pericarditis?
1. Dyspnea MC**
2. Right Sided HF signs: increased JVD, peripheral edema, hepatojugular reflex, N/V
Kussmaul’s Sign: increased JVD with inspiration
3. pericardial knock: high pitched 3rd heart sound due to sudden cessation of ventricular filling in early diastole from thickened inelastic pericardium
60 yo pateint with presents with increased sputum production.
100 temp, RR 20, HR 88, pH 7.44, PaO2 75, PaCO2 40
PE remarkable for inreased AP diameter, diminished breath sounds without wheezes, rhonchi or other signs of respiratory distress
what would be an appropriate treatment for this patient?
broad spectrum antibiotic
sputum production is extremely variable from patient to patient but any increase in sputum with a h/o COPD reported by a patient must be regarded as potentially infectious and treated promptly
transudate vs exudate
transudate is fluid pushed through a capillary due to high pressure within the capillary.
exudate is fluid that leaks around the cells of the capillaries caused by inflammation
Which of the following conditions will produce a transudative pleural effusion?
a. Kaposi’s sarcoma
b. bacterial pneumonia
c. cirrhosis
d. mesothelioma
cirrhosis
the MC causes of transudative pleural effusions in the US are heart failure** and **cirrhosis
other conditions:
severe hypoalbuminemia
nephrotic syndrome
acute atleactasis
myxedema
peritoneal dialysis
obstructive uropathy
end-stage kidney disease
23 yo female with h/o palpitations presents for evaluation
admits to acute onset of rapid heart beating lasting seconds to minutes with associated SOB and CP
patient states she can relieve her symptoms with valsalva
What is the most appropriate diagnostic study?
electrophysiology study
useful in establishing the diagnosis and pathway of complex arrhythmias such as supraventricular tachycardias (SVT)
The finding of egophony is most consistent with:
lobar pneumonia
egophony occurs with consolidation caused by lobar pneumonia
A patient presents with edema, which is most noticeable in the hands and face.
Lab findings include proteinuria, hypoalbuminemia, and hyperlipidemia.
The most likely diagnosis is:
nephrotic syndrome
Proteinuria, hyperlipidemia, and hypoalbuminemia are consistent with nephrotic syndrome
Which of the following can be used to treat chronic bacteiral prostatitis?
a. Penicillin
b. cephalexin (KEFLEX)
c. Nitrofurantoin (MACROBID)
d. Levofloxacin (LEVOQUIN)
LEVOFLOXACIN
chronic bacterial prostatitis (Type II prostatitis) can be difficult to treat and requires the use of fluoroquinolones or trimethoprim-sulfamethoxazole, both of which penetrate the prostate.
25 yo male presents with h/o syncope
patient admits to intermittent episodes of rapid heart beating that resolves spontaneously.
Lead EKG shows delta waves and short PR interval
Which of the following is the treatment of choice for this patient?
a. radiofrequency catheter ablation
b. verapamil (CALAN)
c. Percutaneous coronary intervention
d. Digoxin (LANOXIN)
radiofrequency catheter ablation
TOC on patients with accessory pathways, such as WPW
What are the types of endocarditis and what are the MC organisms associated with each?
acute bacterial endocarditis: S. aureus
subacute bacterial endocarditis: S. viridans
Endocarditis in IV drug userse: MRSA
prosthetic valve endocarditis: staphylococcus epidermis
What is the MC valve associated with acute bacterial endocarditis (NO IV DRUG USE)?
mitral valve
What is the MC valve associated with endocarditis in IV drug users?
tricuspid
What are clinical manifestations of infective endocarditis?
- **fever**, ECG conduction abnormalities
2. Peripheral Manifestations:
Janeway Lesions: painless erythematous macules on palms & soles (emboli/immune)
Roth Spots: retinal hemorrhages with pale centers, petechiae (conjunctiva, palate)
Osler’s Nodes: tender nodules on the pads of the digits
splinter hemorrages of proximal nail bed, clubbing, hepatosplenomegaly.
What is the “Modified Duke Criteria” for Infective Endocarditis?
need 2 MAJOR
or
1 MAJOR + 3 MINOR
or
5 MINOR
Major:
Sustained Bacteremia– 2 + blood cultures by organism known to endocarditis
endocardial involvement– documented by either a + ECHO (vegetation, abscess, valve perforation, prosthetic dehiscence) or clearly established new valvular regurgitation (aortic or mitral regurg)
Minor:
Predisposing condition: abnormal valves, IVDA, indwelling catheters
Fever
Vascular and embolic phenomena: Janeway lesions, septic arterial or pulmonary emboli, ICH
Immunologic phenomena: Osler’s nodes, Roth Spots, + RF, acute glomerulonephritis
+ blood culture not meeting major criteria
+ ECHO not meeting major criteria (ex: worsening of existing murmur)
Treatment for the different types of infective endocarditis
acute (native valve): nafcillin + gentamicin x 4 - 6 weeks OR
vancomycin (if suspected MRSA) + gentamicin
subacute (native valve): penicillin or ampicillin + gentamicin
vancomycin in IVDA
prosthetic valve: vancomycin + gentamicin + rifampin (for staph aureus)
fungal: amphotericin B (treat 6 - 8 weeks)
patients often need surgical intervention for fungal cases
(penicillin and vancomycin have great gram + coverage. Gentamicin has great gram - coverage)
Prophylactic regimen for circumstances that put patients at high risk for infective endocarditis:
(such as prosthetic heart valves, congenital heart disease, dental procedures, respiratory procedures, and procedures involving infected skin/MSK tissue)
amoxicillin 2g 30 - 60 minutes prior to procedure
(clindamycin 600 mg if PCN allergic)
Gallstones usually result in biliary symptoms by causing inflammation or obstruction following migration into the common bile duct OR:
a. cystic duct
b. pancreatic duct
c. duodenal ampulla
d. common hepatic duct
cystic duct
obstruction of the cystic duct by gallstones causes the typical symptoms of biliary colic. once obstructed the gallbladder distends and becomes edematous and inflamed. gallstones can also migrate into the common duct through the cystic duct leading to a condition known as choledocholithiasis
An elderly patient with poorly-controlled Type 2 DM and renal disease develops a fever of 102 orally, productive cough, and dyspnea.
RR 32, labored breathing, and rales at the left base. 90% sats.
Which of the following is the net appropriate step in the management of this patient?
a. administer nebulized corticosteroids
b. admit to the hospital
c. oral antimicrobial therapy
d. endotracheal intubation
admit to hospital
CAP is the most deadly infectious disease in the US. Important risk factors for increased morbidity and mortality: advanced age, alcoholism, comorbid medical conditions, AMS, RR > 30, hypotension, and a
BUN > 30
An 80 yo female presents with pain in her vertebral column. Radiography reveals compression fracture of T12 that is consistent with osteoporotic compression fracture. Which of the following treatment modalities has the potential to cause analgesia of the fracture site with its use:
a. calcitonin nasal spray
b. alendronate
c. Raloxifene
d. combined estrogen and progesterone (Prempro) therapy
Calcitonin
Alendronate is a bisphosphonate that inhibits bone resorption and is effective in building new bone for a pt with osteoporosis but NO ANALGESIA
raloxifene is a selective estrogen receptor modulator and has positive effects on bone density when used to treat osteoporosis but NO ANALGESIA
combined hormonal therapy may have positive effects on bone density but NO ANALGESIA
Clinical Manifestations of Opioid Intoxication AND withdrawal
OPIOID INTOXICATION: euphoria and sedation (drowsiness, slow/slurred speech, impaired memory)
PE: pinpoint pupils (narcotics are miotics), respiratory depression, may also develop biot’s breathing (quick, shallow inspirations followed by irregular periods of apnea), bradycardia, hypotension
OPIOID WITHDRAWAL: lacrimation, HTN, pruritus, tachycardia, N/V/D, piloerections (goosebumps), pupil dilation (mydriasis), flu-like Sx: rhinorrhea
male pt seen in the ED following MVC in which his knee hit the dashboard. pt has posterior knee dislocation that is reduced in the ED. The patient currently has a palpable pulse in the dorsalis pedis and posterior tibial areas. Which of the following studies is mandatory?
Angiography
the popliteal artery is at risk for injury whenever a patient sustains a posterior dislocation of the knee and should be evaluated with an arteriogram despite the presence of pulses
Bony and cartilaginous enlargement of distal interphalangeal joints is commonly seen in which of the following medical conditions?
osteoarthritis
Herberden’s nodes are commonly seen in primary osteoarthritis
