Family Medicine Shelf

Question 1

Four combinations of the tetanus vaccine

Answer 1

Children under 7yo: DTaP and DT

Children over 7 and adults: Tdap and Td

Question 2

When do we give tetanus immunoglobulin

Answer 2

Only if the wound is severe or dirty AND the patient has not been vaccinated in the last 5 years against tetanus

• if the wound is clean and/or minor, no IG

Question 3

When do we screen all pregnant women for asymptomatic bacteruria?

Answer 3

12-16 weeks

*bc it can progress to acute cystitis, acute pyelonephritis –> preterm birth, LBW

Question 4

Treatment for asymptomatic bacteruria or acute cystitis in pregnant women

Answer 4

Nitrofurantoin 5-7 days
Amoxicillin or Augmentin 3-7 days
Fosfomycin single dose

*absolutely no Fluoroquinolones (cartilage) or TMP/SMX (congenital abnormalities, kernicterus)

Question 5

Treatment for acute pyelonephritis in pregnant women

Answer 5

Hospitalize!
Give IV antibiotics (beta-lactams, meropenem)
Switch to 10-14 day course of oral antibiotics once she is afebrile for 24 hours

Question 6

Treatment of acute cystitis or asymptomatic bacteria in pregnant women, if persistent after two more courses of antibiotics

Answer 6

Daily suppressive antibiotic therapy (nitrofurantoin) for the duration of pregnancy

Question 7

Treatment for generalized social anxiety – pharm (2)

Answer 7

SSRIs (PAROXETINE) or SNRIs

+Cognitive behavioral therapy

Question 8

Treatment for performance only social anxiety

Answer 8

Benzodiazepines or beta blocker 30 to 60 minutes before the performance
Cognitive behavioral therapy

*Avoid benzodiazepines if patient has history of substance abuse or does not want sedation

Question 9

Sudden onset severe HA; worst HA Of my life

Answer 9

Subarachnoid hemorrhage

Question 10

Three most common causes of clubbing

Answer 10

1. Lung malignancy –> look for occult malignancy!!!
2. Cystic fibrosis
3. Right to left cardiac shunts

Question 11

Pathophysiology of clubbing

Answer 11

Because of problems in pulmonary circulation –> Megakaryocytes failed to undergo normal fragmentation into smaller parts –> get stuck in the digital circulation –> begin to release PDGF and VEGF –> connective tissue hypertrophy + increased vascularity and permeability = clubbing

Question 12

Zileuton (Zyflo)

Answer 12

5-lipoxygenase (Leukotriene) inhibitor

Question 13

Montelukast (Singulair)

Answer 13

Leukotriene receptor antagonist

Question 14

Jarisch-Herxheimer Reaction

Answer 14

Flu-like syndrome after starting antibiotics bc the killed bacteria start to release pyrogens (fever-inducing substances)
*classically seen in tx of spirochetes (syphillis, Lyme disease, leptospirosis, Q fever)

Question 15

Blood on dipstick, but no RBCs seen on microscopy

Answer 15

Rhabdomyolysis

Question 16

Normal body temp (Celsius vs Fahrenheit)

Answer 16

Celsius = 36-37.5
Fahrenheit = 96.8-99.5

Question 17

Temp in heat stroke vs fever

Answer 17

Heat stroke temp > 104F (41C)

Fever temp >100.4

Question 18

Uncontrolled effluent of calcium from sarcoplasmic reticulum = mechanism of what pathology?

Answer 18

Malignant hyperthermia

After admin of inhaled aesthetics like halothane and succinylcholine

Question 19

Temps seen in malignant hyperthermia

Answer 19

> 113F (45C)

Question 20

Main difference between anorexia nervosa and bulimia nervosa5

Answer 20

Anorexia = low body weight, BMI

Question 21

Treatment for anorexia (3)

Answer 21

CBT
Nutritional rehabilitation
Olanzapine (if the first two don’t work)

Question 22

Olanzapine - brand name and drug class

Answer 22

Olanzapine = Zyprexa
Atypical antipsychotic (dopamine antagonist)

Question 23

Treatment for bulimia nervosa

Answer 23

CBT
Nutritional rehab
SSRI (Fluoxetine = Prozac)

Question 24

Russell’s sign (eating disorders)

Answer 24

Scars/calluses on hands/knuckles seen with repeated self-induced vomiting (hand scrapes against incisors)

Question 25

Main difference btn bulimia nervosa and binge eating disorder

Answer 25

Bulimia has compensatory behavior (purging) | Binge eating disorder has NO compensatory behavior --> pt likely to be overweight

Question 26

The three most common trisomies (# and name)

Answer 26

Trisomy 13 - Patau syndrome Trisomy 18 - Edward Syndrome Trisomy 21 - Down Syndrome

Question 27

Trisomy 18 (Edwards Syndrome) signs (6)

Answer 27

``` Low birth weight Clenched fists (index overlaps 3rd digit, 5th digit overlaps 4th) Microcephaly Prominent occiput (back of head) Micrognathia (small jaw) Rocker bottom feet ```

Question 28

Trisomy 13 (Patau syndrome) signs (5)

Answer 28

``` Cleft lip Flexed fingers + polydactyly Ocular hypotelorism (eyes close together) Bulbous nose Low-set malformed ears ```

Question 29

Chromosomal deletion disease in which protruding metopic suture is characteristic

Answer 29

Cri-du-chat | 5p deletion

Question 30

Clomiphene citrate mechanism of action

Answer 30

Selective estrogen receptor modulator (SERM) Antagonist at estrogen receptors in hypothalamus. Prevents normal feedback inhibition of estrogen against LH/FSH --> causes increased release of LH and FSH from pituitary --> stimulates ovulation. Used to treat infertility due to anovulation (e.g., PCOS). May cause hot flashes, ovarian enlargement, multiple simultaneous pregnancies, and visual disturbances.

Question 31

Ménière's disease pathophys & signs

Answer 31

Abnormal fluid and ion homeostasis in inner ear --> distention of endolymphatic compartment in inner ear Signs = Episodic (20mins-24hours) Vertigo + sensorineural hearing loss and tinnitus Horizontal nystagmus during acute attack +/- postural instability & vomiting with the vertigo

Question 32

Triggers of episodes in Meniere's dz

Answer 32

Anything that causes endolymphatic retention! Alcohol Caffeine Nicotine **high salt foods (low salt intake is one of the lifestyle modifications)

Question 33

Printzmental (variant) angina EKG changes

Answer 33

ST elevations during episode that return to baseline when episode ends * contrast to MI where we have longer lasting ST elevations * contrast to unstable angina where we have ST depressions

Question 34

Young female patient with amenorrhea and other signs suspicious for Turner syndrome. First step in assessment

Answer 34

Pelvic ultrasound | Can show streak ovaries and infantile uterus

Question 35

Mechanism of exercise induced amenorrhea

Answer 35

Low caloric intake:output --> low levels of GnRH and LH --> estrogen deficiency **Hence why you get amenorrhea/infertility but ALSO, vaginal atrophy, breast atrophy, and osteopenia

Question 36

Normal/acceptable PSA value

Answer 36

7ng/dL

Question 37

Volume of urine seen on bladder scan that should make you think obstruction

Answer 37

>100ml

Question 38

Tamsulosin mechanism of action

Answer 38

Alpha-1 blocker --> causes smooth muscle relaxation --> hence use in BPH to allow urination ***selective for alpha receptors in prostate vs vascular alpha receptors

Question 39

Finasteride mechanism of action

Answer 39

5-alpha reductive inhibitor --> blocks this enzyme that converts testosterone to DHT *can be used in combination with alpha-1 blockers in BPH

Question 40

Abnormal grid test: what is abnl, what pathology?

Answer 40

Grid test = grid of parallel vertical & horizontal lines If patient sees the lines as wavy instead of straight = abnl result Think MACULAR DEGENERATION (most common cause of visual loss in industrialized world)

Question 41

NF2 signs (3)

Answer 41

Subcutaneous neurofibromas Cafe-au-last spots Hearing loss (usually bilateral, due to acoustic neuromas)

Question 42

Inspiratory stridor that begins in neonatal period and is loudest by 4-8mos that is worse supine and better when prone

Answer 42

Laryngomalacia | Laxity of supraglottic structures causing stridor, reflux

Question 43

Diagnosis and tx of laryngomalacia

Answer 43

Diagnosis - just clinical OR direct laryngoscopy Tx - keep upright after feeds, acid reducers if reflux **Reassurance - Most will spontaneously resolve by 18mos!!

Question 44

Vitamin deficiency that causes pellagra

Answer 44

Niacin (B3) | Pellagra = diarrhea + dermatitis + dementia

Question 45

Thiamine (B1) deficiency causes Wernicke-Korsakoff and what other pathology?

Answer 45

Beriberi

Question 46

Riboflavin (B2) deficiency signs (6)

Answer 46

1. Cheilosis 2. Glossitis 3. Seborrheic dermatitis (on the genitals only) 4. Pharyngitis 5. Edema 6. Erythema of the mouth

Question 47

Pyridoxine (B6) deficiency signs

Answer 47

1. Depression/irritability 2. Dermatitis 3. Stomatitis 4. Elevated homocysteine --> venous thromboembolic dz and atherosclerosis

Question 48

Four immune deficiency disorders and affect both B and T cells

Answer 48

Severe combined immunodeficiency (SCID) Ataxia–telangiectasia Hyper–IgM syndrome Wiskott-Aldrich syndrome

Question 49

SCID pathophysiology

Answer 49

Genetic defect (in IL-2R gamma chain or adenosine deaminase deficiency) --> failure of T cells to develop --> B cell dysfunction due to absent T cells

Question 50

SCID inheritance patterns (2)

Answer 50

IL-2R defect = X-linked recessive (more common) | Adenosine deaminase deficiency = Autosomal recessive

Question 51

Treatment for SCID

Answer 51

Bone marrow transplant | *the earlier the better --> hence why SCID is included in newborn screen in US

Question 52

Signs of SCID

Answer 52

Recurrent, severe viral, fungal, opportunistic infections Failure to thrive (low weight %ile) Chronic diarrhea

Question 53

In early infancy - eczema and bleeding (eg. post circumcision, bleeding from umbilical stump) due to thrombocytopenia

Answer 53

Wiskott-Aldrich syndrome | *Mutation in WAS gene --> T-cells unable to recognize actin cytoskeleton AND fewer/smaller platelets

Question 54

Most common childhood systemic vasculitis–name and pathophysiology

Answer 54

Henoch-Schonlein purpura | IgA mediated vasculitis of the small vessels, usually after URI

Question 55

Signs of Henoch-Schönlein purpura (4)

Answer 55

1. Palpable purpura (symmetric, over her lower legs, buttocks, arms) **palpable ie we can feel the raised lesions of the purpura + its non-blanching 2. Arthritis/arthralgia (most commonly knees and ankles) 3. Colicky abdominal pain (due to local vasculitis) 4. Renal sx if pt develops nephropathy

Question 56

Tx for Henoch Schonlein purpura (mild v severe)

Answer 56

1. Supportive = NSAIDS + hydration | 2. If severe (nephrotic syndrome, HTN, acute renal failure) = hospitalize and give systemic glucocorticoids

Question 57

What to use to remove foreign bodies in pre-pubertal girl (ex. toilet paper, toys) that is causing vulvovaginitis (2)

Answer 57

Warm water irrigation OR calcium alginite swab

Question 58

Genu varum v genu valgum

Answer 58

Genu varum = bow-legged | Genu valgum = knock-kneed

Question 59

Treatment for rickets in newborn (drug and dose)

Answer 59

Vitamin D repletion with 1000-2000 IU daily

Question 60

Four main acute causes of hemiplegia in children

Answer 60

1. Seizure (=Todd paralysis - postictal period); sx resolve on their own 2. Hemiplegic migraine; sx resolve on their own 3. Ischemic stroke (antithrombin III deficiency, PFO) 4. Intracranial hemorrhage (hemophilia)

Question 61

CT vs MRI, which is better at what?

Answer 61

CT better at showing bone (plus more easily available/faster in emergencies) MRI better ar showing soft-tissue (plus has no ionizing radiation)

Question 62

Nocturnal headaches and morning vomiting

Answer 62

Signs of elevated intracranial pressure! Inc ICP worse at night bc of supine position The inc ICP puts pressure on medullary vomiting center --> N&V

Question 63

Inflammation of the larynx and trachea due to parainfluenza viral infection

Answer 63

CROUP = Laryngotracheitis

Question 64

Clinical signs of croup (3)

Answer 64

Inspiratory stridor Barky, seal-like cough Hoarse voice

Question 65

Tx of croup (mild vs severe)

Answer 65

``` Mild = stridor not happening at rest (ex. only when child cries) = oral glucocorticoids to dec edema/swelling Severe = stridor at rest/resp distress = oral glucocorticoids + nebulized epinephrine to constrict arterioles in the mucosa --> altering hydrostatic pressure --> decreases edema ```

Question 66

Four modifiable risk factors for breast cancer

Answer 66

HRT Nulliparity Inc maternal age at first live birth Alcohol consumption (>2 drinks/day or >7 drinks/week)

Question 67

Two drugs of choice for absence seizures

Answer 67

``` Ethosuximide (Zarontin) Valproic acid (Depakote) ```

Question 68

Clozapine only = risk of agranulocytosis. But both clozapine (Clozaril) and olanzapine (Zyprexa) are notorious for what other side effect?

Answer 68

Metabolic syndrome = weight gain, dyslipidemia, hyperglycemia (new onset diabetes) --> at baseline and follow up: check BMI, fasting glucose/lipids, BP, waist circumference

Question 69

What are the routine labs to measure in pt taking lithium?

Answer 69

Kidney (creatinine, BUN) - bc of nephrogenic diabetes insipidus & chronic interstitial nephritis Thyroid (TSH, T4) - bc of risk of HYPOthyroidism

Question 70

Main antipsychotic associated with prolonged QT at higher doses.

Answer 70

Ziprasidone (Geodon)

Question 71

Pertussis vaccine schedule

Answer 71

Five doses of DTaP from 2mos-6yrs TdaP booster in adolescence (11-18) TdaP booster in pregnancy

Question 72

Pertussis/whooping cough tx

Answer 72

Macrolides! (azithro, erythro, clarithro) | Give empirically even before you confirm diagnosis with bacterial culture/PCR

Question 73

Difference in age of onset of Myasthenia Gravis in men v women

Answer 73

Women: 20s-30s Men: 60s-80s

Question 74

Patient after surgery has bilateral (or one eye worse than other) ptosis. Gets better with ice on the lids for few minutes. Pathology?

Answer 74

Myasthenia Gravis Ice pack test --> slows down ACh breakdown in the synapse --> more ACh available to the few receptors still present *still need to confirm with ACh autoantibody test

Question 75

Other than the ocular signs (ptosis, diplopia), two other systems affected in myasthenia gravis?

Answer 75

``` Bulbar (dysphagia, dysarthria) Respiratory muscles (myasthenic crisis) ```

Question 76

Tx for myasthenia gravis -- medicine (1), surgical (1)?

Answer 76

Pyridostigimine (Achesterase inhibitor) +/- immunotherapy (steroids, azathioprine) Thymectomy

Question 77

In pt with myasthenia gravis, why do chest CT?

Answer 77

To evaluate for thymoma! The autoantibodies are usually due to thymic abnormalities esp hyperplasia

Question 78

Inflammation and edema of the facial nerve

Answer 78

Bell's palsy | Often due to herpes simplex reactivation

Question 79

Disruption of the oculosympathetic chain

Answer 79

Horner syndrome 1. Ipsilateral ptosis 2. Miosis 3. Anhidrosis

Question 80

Lambert-Eaton syndrome, pathophys

Answer 80

Autoantibodies to pre-synaptic calcium channels --> Decreased ACh release **contrast to myasthenia gravis = autoantibodies against post synaptic ACh receptor

Question 81

Lambert-Eaton highly associated with what pathology?

Answer 81

Small cell lung cancer (its a paraneoplastic syndrome)

Question 82

Ranson criteria (5) - used to assess what path? When to assess?

Answer 82

Used to assess prognosis in pancreatitis. Assessed in first 48 hrs. Poor prognosis: 1. Age >55 2. WBC >16,000 3. Glucose >200 4. LDH >350 5. AST >250

Question 83

WBC normal value

Answer 83

4500-10,000

Question 84

Imiquimod - class and used to tx what?

Answer 84

"Immune response modifier" drug | Used to treat: actinic keratosis, superficial BCC & genital warts

Question 85

Pain radiates where in pancreatitis?

Answer 85

To the back | *plus N&V

Question 86

Pain radiates where in gallbladder dzs

Answer 86

To the scapula

Question 87

Pain radiates where in esophageal spasm?

Answer 87

Higher up in the chest

Question 88

Pain radiates where in GERD

Answer 88

*trick question | Typically, there is no pain radiation in GERD

Question 89

Pain radiates where in renal calculi dz?

Answer 89

To the groin

Question 90

Murphy sign - what is it and indicative of?

Answer 90

Cessation of inspiratory effort on deep palpation of RUQ | Indicative of acute cholecystitis

Question 91

Gnawing abdominal pain in center of upper abdomen associated with sensation of hunger

Answer 91

Peptic ulcer disease

Question 92

PUD two top causes

Answer 92

``` #1 - H pylori infection #2 - Excessive use of NSAIDS ```

Question 93

When to conduct an esophagogastroduodenoscopy (EGD) in a patient with suspected GERD (3) ? *since first step is usually?

Answer 93

First step is usually - trial with PPI, H2 receptor blocker | Do EGD if: bleeding, weight loss or dysphagia

Question 94

Patient has biliary colic, + Murphy sign, plus elevated liver enzymes, amylase or lipase. Next step in workup?

Answer 94

ERCP to look for for choledocolithiasis

Question 95

Top two causes of pancreatitis (in order)?

Answer 95

``` #1 - Gallstones! ~60% #2 - Alcohol ~30% #3 - Idiopathic 10-30% ```

Question 96

Dyspepsia - what is it? most common etiology?

Answer 96

Chronic or recurrent discomfort centered in upper abdomen * *Most commonly idiopathic!!! - no etiology found 60% of the time * otherwise, due to PUD, GERD, gastric/pancreatic cancer

Question 97

RDW (red cell distribution width) - what does it tell us?

Answer 97

Measures variation in red blood cell size or red blood cell volume. --> high RDW = high variation in the size of the RBCs

Question 98

Total iron binding capacity (TIBC)

Answer 98

Indirect measure of transferrin Tf = transport protein for iron in serum If "iron binding capacity" is HIGH = transferrin has lots of empty slots on it

Question 99

Ferritin

Answer 99

Form of iron STORED in our cells

Question 100

Rash that begins as pinks pots on extremities which later coalesce and become purple/purpuric

Answer 100

Rocky Mountain Spotted Fever

Question 101

Tx for Lyme disease - early local disease vs early disseminated disease

Answer 101

Early local = Doxycycline or Amoxicillin 14-21 days | Early Disseminated = IV Ceftriaxone/Cefotaxime/Chloramphenicol 14-21 days

Question 102

Mammogram test results categories

Answer 102

BI-RADS (Breast Imaging Reporting And Data System) 0 - incomplete test 1/2 - benign --> routine testing 3 - probably benign --> repeat in 6 mos 4 - suspicious for cancer --> biopsy 5 - highly suggestive of cancer --> biopsy

Question 103

Tinea cruris

Answer 103

Jock itch | Fungal infection of the groin area

Question 104

Two most common causes of small bowel obstruction

Answer 104

Abdominal surgery - adhesions | Hernia

Question 105

Most common cause of iron deficiency anemia

Answer 105

Blood loss

Question 106

RDW in thalessemia

Answer 106

Normal RDW with low MCV (microcytic) | *contrast with iron def anemia where RDW is high

Question 107

Two prophylactic interventions proven to reduce number of pain crises

Answer 107

1. Adequate hydration | 2. Adequate oxygenation

Question 108

Tx for Rocky Mountain Spotted Fever -- non-pregnant adults/children vs pregnant women

Answer 108

Doxycycline (non-pregnant adults, children) | Chloramphenicol (pregnant women)

Question 109

Treatment for tularemia

Answer 109

Streptomycin

Question 110

Erythematous papules on scalp with small black bulbs (nits) at the base of the hair follicles

Answer 110

Head lice

Question 111

Tx for head lice (first, second, third line)

Answer 111

First - Permethrin 1% (Elimite) Second - Permethrin 5% Third - Lindane 1%

Question 112

Pruritic erythematous papules in between fingers, wrists, or around waist (areas where clothes fit tightly) - bite from?

Answer 112

Scabies (Sarcoptes scabiei)

Question 113

Clusters of pruritic erythematous papules on the lower extremities (ankles, legs) - bite from?

Answer 113

Flea bites

Question 114

Teenage boy presents with bilateral gynecomastia. Workup?

Answer 114

Unless you find other abnormalities (ex. small/absent testes) no need to workup further. Benign gynecomastia common in puberty --> usually resolves within 1 year

Question 115

Two most common bugs implicated in acute mastitis

Answer 115

Strep and staph

Question 116

Bug most commonly implicated in cellulitis after cat bite

Answer 116

Pasteurella multocida

Question 117

Crescendo-decrescendo (diamond shaped) murmur

Answer 117

Aortic stenosis

Question 118

Acute bronchitis - when to give antibiotics?

Answer 118

Normally do not treat uncomplicated cases with antibiotics! | Only tx if pt also has COPD or CHF, the elderly or very illl appearing

Question 119

Tx for pertussis

Answer 119

Erythromycin 14 days OR Azithromycin 5 days **doesn't alter course unless administered very early in dz **but it does reduce transmission & hence reduces isolation time from 4 weeks to 1 week

Question 120

Bug most commonly implicated in travelers diarrhea

Answer 120

Enterotoxigenic E. Coli

Question 121

Tx for travelers diarrhea?

Answer 121

Fluoroquinolones (cipro, norfloxacin, ofloxacin) | Alts: TMP/SMX or azithromycin

Question 122

How to differentiate btn peripheral vs central causes of vertigo (3 factors)?

Answer 122

Dix Hallpike maneuver Peripheral: Vertigo reproduced after ~3-10 secs + nystagmus fixed in same direction regardless of how you turn the head + repeating maneuver lessens sx Central (i.e. stroke): Vertigo reproduced immediately + nystagmus changes direction when you turn head + sx same even after repeating

Question 123

In peripheral vestibular disorders, first line therapy?

Answer 123

Antihistamines (ex. meclizine) | They suppress vestibular end-organ receptors and inhibit activation of vagal response.

Question 124

ANP vs BNP - where are they secreted from? Used in diagnosis of what condition?

Answer 124

ANP - released from atria (and partly ventricles) BNP - released from ventricles Both released in response to increased filling pressures/wall stress --> CHF

Question 125

CHF is almost 100% unlikely if BNP level is below what value?

Question 126

D-dimer sensitivity vs specificity and implication?

Answer 126

High sensitivity; low specificity | So mainly useful when negative! i.e. if negative, there is a very low chance patient has a DVT/PE

Question 127

Drug proven to relieve dyspnea in patients with end-stage cancer

Answer 127

Opioids | *unknown mechanism

Question 128

What four factors/signs/sx correlate significantly with diagnosis of acute bacterial cystitis

Answer 128

1. Dysuria 2. Increased frequency 3. Hematuria 4. Back pain (back pain isn't exclusive to pyelo!)

Question 129

Key sign seen in pyelo that you may not see in acute bacterial cystitis?

Answer 129

FEVER!

Question 130

What four signs/sx if present/absent make you think UTI is UNLIKELY?

Answer 130

1. No dysuria 2. No back pain 3. Vaginal discharge 4. Vaginal irritation

Question 131

When do you need to do a urine culture for a patient with suspected UTI?

Answer 131

If the urine dipstick or microscopic evaluation (looking for leukocytes) is negative and so the diagnosis is in question.

Question 132

What do leukocyte esterase and nitrites tell us respectively when we do urinalysis for suspected UTI?

Answer 132

Leukocyte esterase corresponds to pyuria | Nitrites tell us presence of enterobacteria that can convert urinary nitrate to nitrite

Question 133

Woman with frequent UTIs (most commonly postcoital!) - start with what behavioral changes?

Answer 133

Urinating/voiding right after intercourse Acidification of urine (oral ascorbic acid/vit C, cranberry juice) *Don't use things like diaphragm

Question 134

Prophylactic antibiotic therapy for women with recurrent UTIs (first v second v third line)?

Answer 134

1. First line: single dose postcoital antibiotics 2. Second line (if above doesn't work): Daily single dose antibiotics for 3-6 months 3. Third line (if UTIs reoccur after stopping daily dosing for 3-6 months): Daily single dose antibiotics for 1-2 years

Question 135

Woman with recurrent (>4 episodes) dysuria, hematuria but negative dipsticks (other than blood), & negative urine cultures but episodes resolve with antibiotics? Should be thinking what path? What is next step in workup?

Answer 135

Interstitial cystitis (aka bladder pain syndrome)! Do a cystoscopy (looking for ulcerations/fissures in bladder wall) **tx is very complex as this can't necessarily be cured

Question 136

Male patient in his 30s-50s with urinary frequency, urgency, back pain, fever and marked pyuria. No penile discharge and he is acutely ill. Most likely etiology?

Answer 136

Acute prostatitis! * We know UTIs are uncommon in men * Urethritis (gono or non-gono) not likely to cause fever/systemic illness like this

Question 137

For how long is it normal to have ear effusions after tx of AOM? What to do if it lasts longer than that duration?

Answer 137

Nl to have effusions up to 3 months | If longer --> refer to ENT

Question 138

Tx for AOM: First line (mild vs moderate/sever) & Second Line

Answer 138

First line mild : amoxicillin First line mod/severe (otalgia and/or fever >102.5F): high dose Augmentin (90mg/kg/day divided into two doses) Second line: azithromycin

Question 139

Tx for external otitis (swimmers ear) - topical or oral antibiotics?

Answer 139

Topical antibiotics and corticosteroids | *don't need oral antibiotics unless refractory to topicals

Question 140

Patient has bilateral LEE. Three main systems/paths we are thinking?

Answer 140

CHF -- is there dyspnea, JVD, rales? --> get CXR then echo Liver dz -- is there ascites? --> check LFTs Kidney dz (nephritic syndrome, ATN) -- if none of the above signs --> check urinalysis

Question 141

Acute Unilateral LLE --> what to do/think if (1) no trauma/signs of infection versus (2) yes, signs of inflammation/infection like erythema

Answer 141

If no sign of infection --> think DVT --> order doppler | If sign of inflammation/infection --> think cellulitis --> tx with antibiotics

Question 142

Chronic (on/off) unilateral LEE, but no dyspnea, no trauma, no signs of inflammation --> what are we thinking? Tx?

Answer 142

Venous insufficiency --> Compression stockings

Question 143

Most effective, proven cure for enuresis

Answer 143

Bed wetting alarms | *medications more effective in short term - but relapse common when discontinued

Question 144

Nl bladder capacity in children (oz)

Answer 144

child's age + 2 oz

Question 145

Nl post void residual in bladder?

Answer 145

100ml

Question 146

Signs of esophageal reflux in an infant (3)? Diagnosis?

Answer 146

Wet burps Coughing during & after feeding Occasional wheezing *Diagnose with esophageal pH probe

Question 147

Signs of lactose intolerance in infant (4)?

Answer 147

Diarrhea Abdominal pain Bloating Foul-smelling stools

Question 148

Signs of pyloric stenosis in infant

Answer 148

Projectile non-bilious vomitting Abdominal distention +/- palpable mass in abdomen

Question 149

Simultaneous decrease in weight AND height in infant

Answer 149

Familial short stature

Question 150

Weight decreases first, and then height (2) paths

Answer 150

Failure to thrive | Constitutional growth delay

Question 151

Hypothyroidism - changes on growth chart (height vs weight)?

Answer 151

Height velocity decreases first | then the weight changes happen

Question 152

Two red flag signs for severe malnutrition/failure to thrive?

Answer 152

Vital abnormalities: Hypotension + bradycardia *must be hospitalized

Question 153

What happens when you give patient with mono penicillin?

Answer 153

They get a diffuse symmetrical rash * this normally happens bc we misdiagnose mono as strep throat and try to tx with penicillins (amox, ampi) * correct tx = SUPPORTIVE CARE (EBV)

Question 154

Two main causes of GI bleeding in children (in order)? how to differentiate?

Answer 154

``` #1 Meckel's diverticulum (painless) #2 Intussusception (very painful) ```

Question 155

Meckel's diverticulum rule of 2's (5)

Answer 155

``` Occurs in 2% of population Male to female ratio 2:1 Occurs 2 ft from ileocecal valve Usually 2in long 2% of cases have complications ```

Question 156

Test to diagnose Meckel's diverticulum

Answer 156

Nuclear technetium scan (Meckel scan)

Question 157

Meckel's diverticulum pathyophys

Answer 157

Congenital - Persistence of the vitelline duct | **has heterotopic epithelia = gastric & pancreatic tissue

Question 158

Management of thrombosed external hemorrhoid?

Answer 158

Excision * external = below dentate line * thrombosed = hard/nodular appearance

Question 159

Management of internal hemorrhoids

Answer 159

Rubber-band ligation

Question 160

Pt with bright red blood after painful bowel movement, followed by dull ache/spasm in anal canal that resolves after several hours; no abnormalities seen on external examination

Answer 160

Anal fissure | *key is that the pain resolved; in thrombosed internal hemorrhoid may have pain but it would not resolve

Question 161

Only calcium channel blocker proven to work in migraine prophylaxis

Answer 161

Verapamil

Question 162

Most studied prophylactic agent for migraines

Answer 162

Beta blockers

Question 163

Which TCA has strongest efficacy evidence for migraine prophylaxis?

Answer 163

Amitriptyline

Question 164

Two main migraine abortives

Answer 164

1st line - triptans | 2nd line - ergot derivatives

Question 165

Cluster headaches prophylaxis (4)

Answer 165

* *only give the drugs during cluster!!! 1. Nifedipine (calcium channel blocker) 2. Prednisone 3. Indomethacin 4. Lithium

Question 166

Mainstay treatment of cluster headaches (during attack)?

Answer 166

100% Oxygen via nasal cannula!

Question 167

Managagement of tension-type headaches?

Answer 167

Trial of NSAIDs and follow up if that doesn't work | *try to avoid opioids bc TTH is usually chronic

Question 168

Painless hematuria without other sx

Answer 168

Bladder carcinoma

Question 169

Risk factors for bladder carcinoma

Answer 169

Male Smoking Working with aromatic amines (dye, paint, aluminum, textiles, rubber)

Question 170

Pseudohematuria (looks like there's blood but there isn't) caused by what foods (2)?

Answer 170

Beets Blackberries Food dyes

Question 171

Pseudohematuria (looks like there's blood but there isn't) caused by what meds ?

Answer 171

1. Chloroquine 2. Metronidazole 3. Phenytoin 4. Rifampin 5. Sulfasalazine (UC)

Question 172

ASO titer

Answer 172

?

Question 173

Two sleep aids useful for sleep ONSET problems

Answer 173

Zolpidem (Ambien) | Eszopiclone (Lunesta)

Question 174

Sleep aid useful for sleep MAINTENANCE problems

Answer 174

Zaleplon (Sonata)

Question 175

In Hep A, patients have prodrome flu-like illness followed by jaundice. At which stage are they most infectious?

Answer 175

During the prodrome

Question 176

Baby born to mom with positive HBsAg. Likely to develop chronic dz or not?

Answer 176

When acquired early in life, the majority of those infected are likely to develop chronic disease!

Question 177

Functional (urinary) incontinence

Answer 177

Incontinence due to a limitation that does not allow patient to void in the bathroom ex. paralysis, severe dementia ie. nothing to do with anatomy

Question 178

Urge (urinary) incontinence

Answer 178

``` **most common type of incontinence in the elderly Detrusor muscle (muscle surrounding bladder) hyperactivity --> strong urge followed by involuntary loss of urine ```

Question 179

Stress (urinary) incontinence

Answer 179

Loss of urine when pt has increased intra-abdominal pressure bc of weak pelvic floor muscles ex. coughing, sneezing, laughing, exercising *women>men for obv reasons

Question 180

Overflow (urinary) incontinence

Answer 180

Urine loss due to overdistention of the bladder Think post-void residual > 200mL Think BPH, neurogenic bladder (due to longstanding diabetes, alcoholism, degenerative disc dz)

Question 181

Normal post-void residual

Answer 181

200mL is abnl | 50-200mL = indeterminate

Question 182

Which type of urinary incontinence is most responsive to pelvic floor strengthening (Kegel) exercises

Answer 182

Stress incontinence | *makes sense bc it is due to weak pelvic floor musculature

Question 183

Medical management for urge incontinence (drug class + two examples)

Answer 183

Anticholinergics! ie prevent detrusor muscle hyperactivity! Oxybutynin (Ditropan) Tolterodine (Detrol)

Question 184

Medical management for overflow incontinence due to BPH (two exs)

Answer 184

(1) Finasteride (5-alpha-reductase inhibitor) --> block DHEA to testosterone --> reduces the prostatic hyperplasia (2) Terazosin (alpha-1 selective blocker) --> muscle relaxation

Question 185

Thiazide diuretics -- will cause urinary leakage, urgency or both or retention?

Answer 185

Urgency (and frequency) bc of increased filling | BUT NOT leakage (bc does not affect the sphincters)

Question 186

Calcium channel blockers -- will cause urinary leakage, urgency or both or retention?

Answer 186

Will cause urinary RETENTION (bc blocking contraction of detrusor muscle, PLUS the sphincters)

Question 187

Alpha blockers -- will cause urinary leakage, urgency or both or retention?

Answer 187

Leakage BUT NOT urgency (bc the drug will cause relaxation of the sphincters; leakage throughout day so never builds up to cause urgency)

Question 188

Beta blockers -- will cause urinary leakage, urgency or both or retention?

Answer 188

Both! | *need to read up on explanation

Question 189

The four hereditary hyperbilirubinemias (in order of descent through hepatocyte)

Answer 189

1. Gilbert 2. Crigler-Najjar 3. Dubin-Johnson 4. Rotor

Question 190

Pathophys of Gilbert hyperbilirubinemia? --> unconj or conj hyperbilirubinemia?

Answer 190

Mildly low UDP-glucoronyltransferase --> back up --> decreased bilirubin uptake INTO the hepatocyte --> unconj hyperbili

Question 191

Pathophys of Crigler-Najjar hyperbilirubinemia? --> unconj or conj hyperbilirubinemia?

Answer 191

ABSENT UDP-glucoronyltransferase --> NO bili conjugation --> unconj hyperbili

Question 192

Pathophys of Dubin-Johnson hyperbilirubinemia? --> unconj or conj hyperbilirubinemia?

Answer 192

Problem getting conjugated bili OUT of the hepatocyte --> conj hyperbili

Question 193

Pathophys of Rotor hyperbilirubinemia? --> unconj or conj hyperbilirubinemia?

Answer 193

Same as Dubin-Johnson BUT even milder | Problem getting conjugated bili OUT of the hepatocyte --> conj hyperbili

Question 194

Jaundice, kernicterus, and increased unconj bili early in life

Answer 194

Crigler-Najjar Type I

Question 195

Difference btn Type I and Type II Crigler-Najjar

Answer 195

Type II is less severe than Type I | Type II responds to PHENOBARBITAL (mech: increases synthesis of UDP-glucoronyltransferase in the liver)

Question 196

Tx for Crigler-Najjar Type I (2)

Answer 196

Plasmapharesis + Phototherapy

Question 197

Mostly asymptomatic or mild jaundice + increased unconj bili only with fasting or stress

Answer 197

Gilbert Syndrome

Question 198

Grossly black liver, hyperbilirubinemia?

Answer 198

Dubin-Johnson | *bc the conj bili cannot be excreted --> builds up in the liver

Question 199

Wilson disease --> pathophys

Answer 199

Problem excreting copper from hepatocytes --> [form of copper in circulation = ceruloplasmin] --> low serum ceruloplasmin + copper accumulation in the liver/brain/cornea/kidneys/joints

Question 200

Signs of Wilson dz (8)

Answer 200

``` Cirrhosis Corneal deposits (Kayser-Fleischer rings) Hepatocellular Carcinoma Asterixis Hemolytic anemia Dementia Dyskinesia Dysarthris ```

Question 201

Tx for Wilson disease (2)

Answer 201

Copper chelation! | Penicillamine or Trientine

Question 202

G6PD deficiency --> unconj or conj hyperbili?

Answer 202

Unconjugated | *think back up due to intravascular hemolysis

Question 203

Most common cause of conjugated hyperbili in pts

Answer 203

Viral hepatitis | **Accounts for 75% of jaundice in pts

Question 204

Most common cause of conjugated hyperbili in pts >60yo

Answer 204

Extrahepatic obstruction (gallstones, pancreatic cancer)

Question 205

Functional hypothalamic amenorrhea causes (4)

Answer 205

Anorexia Rapid weight loss Rigourous exercise Significant emotional stress

Question 206

Pt with amenorrhea, given Provera (medroxyprogesterone acetate) challenge 7 days, and then has period --> most likely etiology?

Answer 206

PCOS Fact that patient is bleeding means they have no problems with estrogen BUT they have a problem making progesterone --> prob bc they are not ovulating = no corpus luteum to secrete progesterone

Question 207

Pt with amenorrhea, initial workup negative --> progestin challenge = no withdrawal bleeding --> estrogen-progestin challenge = still no withdrawal bleeding. Most likely etiology?

Answer 207

Outflow tract obstruction / Anatomic defect

Question 208

Signs of amphetamine withdrawal (4)

Answer 208

Psychomotor slowing: Hypersomnolence + Anhedonia | BUT also increased appetite + Existential crisis

Question 209

Withdrawal of what drug causes hyperalert confusion

Answer 209

Alcohol | *overly sensitive to environmental stimuli, startled very easily

Question 210

Which antidepressant has the longest half-life and therefore is less likely to cause discontinuation syndrome/withdrawal compared to the others?

Answer 210

Fluoxetine [Prozac] (half life = 84-144hrs) | *compare to other avg 20hrs

Question 211

Pt with chronic N&V, longstanding DM2, N&V worse after eating, sometimes vomits undigested food --> etiology?

Answer 211

Gastroparesis

Question 212

Best antiemetic for gastroparesis (name, mechanism, main adverse effect)

Answer 212

Metoclopramide (Reglan) D2 receptor antagonist --> inc resting tone and contractility of gut Adverse: Blocks dopamine --> parkisonism

Question 213

Best antiemetic for chemo patients or post op (name, mechanism)

Answer 213

Ondansetron (Zofran) | 5-HT antagonist --> CENTRAL-ACTING antiemetic (ie acts on area postrema (vomiting center in medulla)

Question 214

Best antiemetic for motion sickness (name, mechanism)

Answer 214

Scopolamine (Transderm Scop) | Anticholinergic

Question 215

Promethazine (Trade name, mechanism)

Answer 215

Promethazine = Phenergan | H1 blocker

Question 216

Coming up with differential for N&V -- N&V in the mornings before eating, differential (4)

Answer 216

1. Pregnancy 2. Uremia 3. Alcohol withdrawal 4. Increased ICP (+dizziness, HA)

Question 217

Coming up with differential for N&V -- N&V after any meal (regardless of meal content, differential (2)

Answer 217

1. Gastroparesis 2. Pancreatitis * Cholelithiasis if after FATTY meals only

Question 218

Coming up with differential for N&V -- N&V without any clear association with food, differential (2)

Answer 218

Vestibular disorders

Question 219

Best imaging technique to visualize herniated disc

Answer 219

MRI

Question 220

Best imaging technique to visualize spinal stenosis

Answer 220

CT scan

Question 221

Spurling maneuver (what is it and what does it test for)?

Answer 221

Neck compression test -- pt bends head to side and rotates toward side of pain and you exert downward pressure Should reproduce NERVE ROOT INJURY/SX

Question 222

Spurling maneuver that does not reproduce nerve root sx but only causes neck discomfort -- etiology

Answer 222

Non-specific mechanical pain

Question 223

Tx for cervical dystonia with the best evidence

Answer 223

Botox | *helps but less evidence: PT, neck collar, stretching techniques, ice/heat

Question 224

Pt with palpitations -- xtics that lead you to think it is of cardiac etiology rather than other (4)?

Answer 224

1. Male sex 2. Describing the sx as feeling like an 'irregular heartbeat' 3. Personal h/o heart dz 4. Event duration >5mins * FMH NOT a factor

Question 225

Pt with palpitations that she describes as a "flip-flop" in her chest - which cardiac arrhythmia?

Answer 225

Ventricular premature beats | *random, episodic, instantaneous beats

Question 226

Pt with sudden rapid BUT regular heart beat that lasts a long time

Answer 226

Paroxysmal Supraventricular Tachycardia (PSVT) | *most common causes: Wolff Parkinson White, Digitalis toxicty

Question 227

What kind of arrythmia would stimulant overuse cause?

Answer 227

Sinus tachy

Question 228

Pt says he can "feel his heartbeat", + has holosystolic murmur that increases with Valsalva Hint: but is not aortic stenosis

Answer 228

Hypertrophic obstructive cardiomyopathy

Question 229

Delta waves on EKG (path + tx)

Answer 229

Wolff-Parkinson-White syndrome * pts have accessory pathway which directly connects the atria and ventricles, thereby allowing electrical activity to bypass the AV node * tx only if symptomatic --> ablation

Question 230

When should you admit and tx inpatient for PID?

Answer 230

Woman is: (1) Pregnant (2) Severe = fever + vomiting (3) Can't rule out surgical emergency

Question 231

Outpatient tx for PID?

Answer 231

Ceftriaxone 250mg IM + Doxycycline 100mg BID for 14 days +/- metronidazole 500mg BID for 14 days

Question 232

3 most likely culprits of PID

Answer 232

Neisseria gonorrhea + Chlamydia trachomatis (most common) | Anaerobes (E. Coli)

Question 233

Pt with sore throat, fever+aches+fatigue, exudative pharyngitis + soft palate petechiae + posterior cervical adenopathy

Answer 233

Infectious mononucleosis

Question 234

7yo with sore throat -- fever/chills +myalgia+pain on swallowing, plus ANTERIOR adenopathy, erythematous tonsils and edema of the uvula -- etiology?

Answer 234

Group A strep pharyngitis *edema of the uvula is very specific to GAS All the other sx/signs simply point to pharyngitis

Question 235

First line tx for GAS pharyngitis in children? Second line?

Answer 235

Liquid amoxicillin (could technically use penicillin but liq penicillin tastes nasty) If allergic to penicillin: 2nd line: Cephalosporin/Macrolide **GAS is highly resistant to tetracycline, sulfonamides, fluoroquinolones

Question 236

Management of asymptomatic child with recurrent positive rapid strep antigen test?

Answer 236

No antibiotics 20% of school age kids are GAS carriers! *No need to tx bc these kids almost never have complications from the infection and they (asymptomatic) don't really contribute to transmission

Question 237

Tx for combined laryngitis + pharyngitis

Answer 237

Supportive! | It is most commonly viral

Question 238

Centor criteria

Answer 238

``` For Group A strep infection 1. Tonsillar exudates 2. Tender anterior cervical adenopathy 3. Fever 4. NO cough If all 4 --> tx with penicillin --> no need for further testing If 3 --> 40-60% chance it is GAS ```

Question 239

Epididymitis -- most common cause in men

Answer 239

Ascending urethritis from gonorrhea or chlamydia

Question 240

Epididymitis -- most common cause in men >35yo

Answer 240

Ascending prostatitis from enteric gram-negative rods (Enterobacter)

Question 241

Cremasteric reflex

Answer 241

You pinch or brush the inner thigh --> the testicle on the same side should retract toward the inguinal canal *this will be absent in testicular torsion

Question 242

Prehn sign

Answer 242

``` Positive Prehn sign = pt with testicular pain: pain is relieved when you elevate the testicle while the patient is supine if positive (ie pain is relieved) --> think epididymitis if negative (ie pain not relieved) --> think torsion ```

Question 243

What foods play a role in increasing acne in teenagers

Answer 243

None! All myths. Contributory factors: 1. Occlusion/pressure on skin (ex leaning on hands, touching face) 2. Emotional stress 3. Medications

Question 244

First line tx for mild acne

Answer 244

COMBINATION therapy! Topical antibiotics + benzoyl peroxide gel + topical retinoids *antibiotic & benzoyl peroxide during day, retinoid at night

Question 245

When do we use ORAL retinoids for acne?

Answer 245

Acne resistant to all other therapies including ORAL/SYSTEMIC antibiotics

Question 246

Isoretinoin can cause what severe advere effect? and therefore should not be combined with what other drug that does the same?

Answer 246

Pseudotumor cerebri! | Must avoid combining with TETRACYLCINE (often used as topical antibiotic for acne)

Question 247

First line tx for rosacea (drug class + 2 exs)

Answer 247

Oral antibiotics! | Minocycline or Doxycycline

Question 248

Skin nodule that 'popped' and has been growing rapidly ever since + kind of looks like molluscum or BCC

Answer 248

Keratoacanthoma *clue is that it is fast growing; BCC is slow growing & the the central popped part is much bigger in keratoacanthoma than in molluscum

Question 249

Herald patch, followed days later by Christmas tree distributed rash -- path and tx?

Answer 249

Pityriasis rosea Self-limited --> resolves in 6-8 weeks Symptomatic relief: antihistamines or topical steroids to help with itching

Question 250

Impetigo -- micro culprit?

Answer 250

Staph aureus | *minority of cases due to GAS

Question 251

Impetigo -- tx?

Answer 251

Topical antibiotics -- MUPIROCIN (Bactroban)

Question 252

Hot tub folliculitis -- bug? tx?

Answer 252

Pseudomonas! USUALLY ONLY DO SUPPORTIVE CARE (SELF-LIMITING) Only tx if severe or pt is immunocompromised Tx = ciprofloxacin 500mg BID

Question 253

Best management for recurrent oral herpes?

Answer 253

Chronic suppression with valacyclovir or famciclovir *Pulse dosing (ie treating at first sign of outbreak) may shorten or reduce severity of the outbreak but overall, chronic suppression can prevent outbreaks to begin with so better choice depending on frequency

Question 254

Antiviral therapy for herpes zoster/shingles most effective in reducing duration of lesion and pain if administered in first __ hrs?

Answer 254

First 72 hours

Question 255

Management of postherpetic neuralgia?

Answer 255

Often have to use narcotics | *Corticosteroids given during outbreak DO NOT help prevent postherpetic neuralgia

Question 256

Kid with 3 days low grade fever, runny nose and then later gets slapped cheeks rash -- micro culprit?

Answer 256

Parvovirus 19 = Erythema infectiosum = Fifth dz of childhood

Question 257

Tx for tinea capitis

Answer 257

SYSTEMIC antifungals: 1st line: Oral Griseofulvin (6-12 wks) or Terbinafine (4-6 weeks *Terbinafine preferred bc shorter tx course

Question 258

Tinea corporis -- micro culprit?

Answer 258

Trichophyton rubrum

Question 259

Well demarcated plaque with central scaling

Answer 259

Tinea corporis

Question 260

Main difference in appearance of BCC vs molluscum?

Answer 260

BCC will be surrounded by telangiectasia

Question 261

Molluscum -- micro culprit?

Answer 261

Poxvirus * in adults this is most often sexually transmitted [skin-to-skin contact] * also see in kids, but not sexually transmitted

Question 262

Tx for molluscum contagiosum?

Answer 262

Most will resolve on their own within months | BUT can remove with cryotherapy, cautery, or curettage

Question 263

Is it typical to have pain with conjunctivitis?

Answer 263

No! Typical sx = redness, itching, tearing, discharge *If pain present --> think something more serious ex. uveitis, acute angle glaucoma, scleritis, foreign body, corneal abrasion

Question 264

Most common viral culprit in conjunctivitis? Transmission?

Answer 264

Adenovirus * can be transmitted through ocular AND respiratory secretions * also by fomites on towels/equipment

Question 265

Palpable preauricular adenopathy + conjunctivitis

Answer 265

VIRAL conjunctivitis *most commonly, adenovirus Viral conjunctivitis > bacterial (85%:15%)

Question 266

Signs of bacterial conjunctivitis (4)

Answer 266

Purulent discharge Pain Photophobia Gritty sensation in the eye

Question 267

Tx for nonherpetic viral conjunctivitis

Answer 267

Cold compresses + lubricating eye drops

Question 268

What do you see on fluorescein staining in herpetic conjunctivitis? Treatment?

Answer 268

Fluroescein: Corneal dendrites Tx: Antiviral eye drops

Question 269

Bugs most commonly implicated in bacterial conjunctivitis?

Answer 269

Strep and Staph | *contrast to viral = adenovirus

Question 270

Pt with suspected bacterial conjunctivitis (purulent discharge etc) but not responding to cipro opthalmic solution. Next step in tx?

Answer 270

Pt may have MRSA conjunctivitis! | Tx same way as MRSA in other parts of body --> TMP-SMX (Bactrim)

Question 271

Eye infection often associated with systemic autoimmune processes ex RA, Wegeners that manifests as decreased vision + deep, boring pain in the eye BUT nl pupillary response

Answer 271

Scleritis

Question 272

Signs of acute glaucoma

Answer 272

Pain Decreased vision Redness Dilated pupil

Question 273

Acute sinusitis -- most common micro culprit?

Answer 273

Strep pneumo

Question 274

Tx for shoulder dislocation

Answer 274

Relocation, immobilization for 7-10 days and PT with ROM and muscle strengthening exercises

Question 275

Lateral knee pain in cyclists or long distance runners that worsens with activity

Answer 275

Iliotibial band syndrome * think athletes who do repetitive knee flexion activities * will also have pain/tightness over the IT band

Question 276

Leg/knee twisting injury --> feeling 'pop' --> immediate knee effusion BUT still able to bear weight

Answer 276

ACL tear | *contrast to PCL tear --> need direct force to the knee

Question 277

Ottawa ankle rules

Answer 277

Guide as to whether or not to get xrays after an ankle sprain 1. Pt unable to walk 4 steps immediately after injury or in office (ie inability to bear weight) 2. Tenderness over distal 6cm of tibia/fibula (incl malleolus) 3. Midfoot or navicular tenderness 4. Tenderness over the proximal 5th metatarsal

Question 278

In which pts do we do a tilt table test? Abnl result indicates what path?

Answer 278

Pts with unexplained recurrent syncope, in whome we've ruled out cardiac causes (incl arrythmias) Abnl result --> vasovagal syncope

Question 279

Glabellar reflex / Myerson sign

Answer 279

You tap on patients forehead repeatedly --> Orbicularis oculi muscle contracts causing blinking, but this should stop after 5-10 taps If blinking continues = Myerson Sign Commonly seen in Parkinson pts

Question 280

Only drug proven to delay functional impairment and dz progression in Parkinson dz

Answer 280

Selegiline = Eldepril (MAOI) | All the others (incl carbidopa-levodopa) provide symptomatic relief only

Question 281

Strawberry cervix

Answer 281

Red macules on cervix Seen in TRICHOMONAS +yellow-green discharge

Question 282

Tx for BV

Answer 282

Metronidazole

Question 283

When do we do peak flow measurements in pt with SOB + wheezing

Answer 283

If they have known asthma and no fever/sputum/rhonchi

Question 284

Inability to achieve erection - most common cause

Answer 284

Vascular problems! | *more common than psych stressors

Question 285

Male patient with complaints of low libido (desire/interest) but no other sx. Test to order?

Answer 285

Morning FREE testosterone

Question 286

Antidepressant least likely to cause sexual dysfunction?

Answer 286

Buproprion

Question 287

Drug to give in premature ejaculation

Answer 287

SSRIs! Since they increase orgasmic threshold -- use the side effect to your advantage *premature ejaculation is the most common sexual dysfunction in men (up to 29% of men)

Question 288

Man with ED in whom we get morning free T which is low, next step?

Answer 288

Test FSH, LH and prolactin - If FSH/LH low; prolactin nl = pituitary/hypothalamic failure - If FSH/LH high; prolactin nl = testicular failure - If FSH/LH low; prolactin high = pituitary adenoma --> order CT/MRI!

Question 289

Hypoactive sexual desire disorder (low desire/libido) -- two most common causes (other than meds)

Answer 289

1. Relationship problems | 2. Androgen deficiency

Question 290

First line tx for orgasmic dysfunction in women

Answer 290

Directed self-stimulation

Question 291

GGT sensitivity vs specificity in alcohol abuse (low v high)?

Answer 291

``` Sensitivity = high Specificity = low (also elevated in NAFLD, DM, pancreatitis, hyperthyroid, CHF, anticonvulsant use) ```

Question 292

Ethyl glucuronide (EtG) -- what does it test for?

Answer 292

(Urine test) Tests for RECENT alcohol consumption | *but doesn't tell us anything about level of consumption or abuse (like GGT)

Question 293

Most specific test for alcohol abuse

Answer 293

MCV! | *Elevated MCV is 96% specific for alcohol abuse (vs GGT is 76% specific)

Question 294

Naltrexone mech of action in alcohol abuse

Answer 294

Reduces the reinforcing effects of alchol -- prevents pts from becoming DRUNK

Question 295

Most effective med in preventing relapse in alcoholics?

Answer 295

Acamprosate | *affects GABA and glutamine neurotransmission -- has greater and longer lasting effect than naltrexone

Question 296

Patient who wants to quit smoking but failed on nicotine patch -- next step?

Answer 296

Combine patch with gum (or other nicotine replacement method) *pt probably just needs higher baseline level of nicotine to replace their old level from smoking

Question 297

Varenicline mech of action

Answer 297

Varenicline = Chantix | Selective nicotinic receptor partial agonist

Question 298

Buproprion not safe in patients with what med hx?

Answer 298

Seizure disorder | *buproprion has been shown to induce seizures

Question 299

Signs of cocaine withdrawal

Answer 299

**doesn't have many physiologic sx like other drugs | Mainly a "crash" = depression, fatigue

Question 300

Diaphoresis, restlessness, irritability, severe pain, abdominal cramps, diarrhea -- signs of withdrawal from what drug?

Answer 300

Opiates (long-acting ones) | *short-acting ones like heroin = lacrimation, rhinorrhea, excessive yawning

Question 301

First line tx for rheumatoid arthritis

Answer 301

Disease Modifying Anti-Rheumatic Drugs (DMARDs) -- Methotrexate, Sulfasalazine, TNF-alpha inhibitors MUST refer to rheumatology asap to start these - earlier tx with DMARDs reduces progression/devt of deformity

Question 302

Difference in appearance of joint aspirate of gout vs pseudogout

Answer 302

Gout - needles; NEGATIVE birefrengence | Pseudogout - rhomboids; POSITIVE birefrengence

Question 303

Difference in substance that precipitates in gout vs pseudogout

Answer 303

``` Gout = Mono Sodium Urate crystals Pseudogout = Calcium Pyrophosphate crystals ```

Question 304

Gout, pseudogout & infectious arthritis will all have cloudy aspirate and +/- elevated WBC. How can you differentiate infectious arthritis (other than polarizing microscope)

Answer 304

Low glucose! | Infectious arthritis will have low glucose, but glucose will be normal in gout/pseudogout

Question 305

Both OA and RA will have clear joint aspirate with overall WBC count in nl range -- how to differentiate the two from the aspirate?

Answer 305

PMN count In RA, >50% PMNs In OA,

Question 306

First line for gout ATTACK

Answer 306

NSAIDs or colchicine

Question 307

First line for gout PREVENTION

Answer 307

Allopurinol or Probenecid

Question 308

Mechanism of action of allopurinol vs probenecid

Answer 308

Allopurinol inhibits xanthine oxidase --> decrease conversion of xanthine to uric acid Probenecid inhibits reabsorption of uric acid in the PCT

Question 309

What organ systems are most commonly involved in extra-articular manifestation of RA (3)?

Answer 309

Vessels --> Vasculitis Lungs --> Interstitial lung dz (look for cough/dyspnea) Eyes --> chronic dry eye

Question 310

Four categories of asthma severity

Answer 310

Intermittent Mild persistent Moderate persistent Severe persistent

Question 311

Daytime sx in intermittent vs mild p vs mod p vs severe p asthma

Answer 311

Intermittent - 2days/wk but not daily Moderate persistent - Daily Severe persistent - Throughout the day

Question 312

Nighttime sx in intermittent vs mild p vs mod p vs severe p asthma

Answer 312

Intermittent - 1x/week but not nightly | Severe persistent - Nightly

Question 313

Pt with asthma who uses SABA daily -- severity classification?

Answer 313

Moderate persistent | *also makes sense bc for this category, daytime sx daily

Question 314

Patient with peak flow (FEV1) 80% predicted. Next step?

Answer 314

Review meds, technique and decide whether or not to step up FEV1 81-100% = green zone --> maintain FEV1 50-80% = yellow zone --> review +/- step up FEV1 pt needs immediate attn

Question 315

Tx for intermittent asthma

Answer 315

SABA inhaler PRN

Question 316

Tx for mild persistent asthma

Answer 316

SABA + Low-dose inhaled steroid *once you move up from intermittent to any of the persistent categories, you MUST add a steroid ***you never use a LABA without a steroid!!!!!

Question 317

Tx for moderate persistent asthma

Answer 317

SABA + Low-dose inhaled steroid + LABA OR SABA + medium-dose inhaled steroid

Question 318

Tx for severe persistent asthma

Answer 318

SABA + high-dose inhaled steroid + LABA

Question 319

Pt with persistent asthma but intolerant of side effects of inhaled corticosteroids -- what to add to SABA?

Answer 319

Leukotriene receptor antagonist | *also good for kids with asthma exacerbated by allergies

Question 320

Spondylolisthesis - what is it? most at risk population?

Answer 320

Anterior displacement of a vertebrae in relation to the one below it *most common cause of low back pain in pts/athletes

Question 321

Description of the low back pain in spondylolisthesis | (3)?

Answer 321

No inciting event No increase in pain with movement No radiation to legs

Question 322

Which antidepressants have been proven effective in helping chronic pain when used as adjuvant to other analgesics (ex. opioids, NSAIDs)?

Answer 322

TCAs | **SSRIs are not as effective

Question 323

Chronic bronchitis - clinical definition

Answer 323

Productive cough lasting at least 3 consecutive months over 2 consecutive years *Falls under COPD! = chronic bronchitis, emphysema

Question 324

Pt with productive cough suggestive of chronic bronchitis - first test to order to establish diagnosis?

Answer 324

Office spirometry = cornerstone of diagnosis for all COPD | Also helps assess severity, and monitor response to tx

Question 325

Single most important intervention that improves natural history of COPD (other than smoking cessation in smokers)?

Answer 325

Supplemental oxygen | **COPD does not respond to steroids!! --> inc risk of pneumonia

Question 326

First line therapy for COPD (improves sx etc, not natural hx)

Answer 326

Bronchodilators: | ipratropium > albuterol bc ipratropium (Atrovent) has longer duration + no sympathomimetic effects

Question 327

(It is recommended to give patients with COPD antibiotics during exacerbations (improves outcomes). Which antibiotics recommended (3)?

Answer 327

Azithromycin Ciprofloxacin Augmentin *NOT reg amox, TMP-SMX, doxy

Question 328

The 2 most significant risk factors for chronic renal insufficiency/dz

Answer 328

Diabetes & HTN

Question 329

Best lab indicator of renal failure?

Answer 329

GFR **DO NOT use creatinine bc this can be nl in elderly people with chronic renal dz (bc they have less muscle mass to begin with)

Question 330

What is the first lab abnormality you will see in patient with low GFR/chronic renal dz?

Answer 330

Anemia! (low epo induced anemia @ GFR 60mL/min *Other electrolyte abnormalities ex. hyponatremia, hyperkalemia, hyperphosphatemia &metabolic acidosis due to loss of bicarb) seen LATE dz - GFR below 30mL/min

Question 331

List the criteria for Stage I-V CKD

Answer 331

``` Stage I - GFR >90 but proteinuria, hematuria, microalbuminuria Stage II - GFR 60-89 Stage III - 30-59 Stage IV - 15-29 Stage V - ```

Question 332

First line drug to prevent progression of kidney damage in pt with HTN

Answer 332

ACE inhibitor | **regardless of whether they are normotensive!!

Question 333

Most common cause of death in patients with chronic kidney disease?

Answer 333

Cardiovascular dz | *often happens before they even reach need for dialysis -- reason unclear, most likely uremic mileu

Question 334

Allodynia

Answer 334

Severe pain from innocuous stimuli ex. bedsheet brushing against skin

Question 335

Other than anticonvulsants like gabapentin, what other drug class can you use to tx neuropathic pain?

Answer 335

TCAs -- amitriptyline

Question 336

Pt on max dose of long-acting opioid + NSAIDs + anticonvulsant but still has uncontrolled pain -- next step in mgmt?

Answer 336

Switch to lower dose of different opioid Pt has most likely developed tolerance to the opioid bc of upregulation of NMDA receptors *could also add TCA but changing the opioid will provide better control

Question 337

Which liver tests reflect hepatocellular injury (versus hepatic function) (4)?

Answer 337

AST, ALT, LDH, alk phos | *abnl values suggest ACUTE processes

Question 338

Which liver tests reflect hepatic (synthetic) function (versus hepatocellular injury ) (4)?

Answer 338

Albumin Prothrombin time Bilirubin *abnl values suggest CHRONIC processes (bc it takes time to liver to be damaged enough to cause synthetic dysfunction)

Question 339

Most common cause of death in patients with cirrhosis

Answer 339

Bleeding varices

Question 340

List the criteria for Class I-IV of CHF

Answer 340

Class I - No limitation of activity Class II - Comfortable @rest, but sx (fatigue/dyspnea/ palpitations/angina with ordinary activity Class III - Comfortable @rest, but sx with less-than-ordinary activities Class IV - sx at rest and increased sx with activity

Question 341

What intervention (non-pharm) has been shown to improve function in CHF

Answer 341

Alcohol cessation if CHF due to alcoholic cardiomyopathy *smoking cessation, controlling BP, DM, is always good, but does not lead to functional improvement/improve damage already sustained

Question 342

Two first-line tx that should been given to ALL CHF pts unless there is contraindication

Answer 342

``` #1 ACE inhibitor --> reduces preload, afterload, cardiac output AND blocks RAAS #2 Diuretics ```

Question 343

Name of diuretic to combine with loop diuretics (usually) furosemide in pts with CHF but refractory edema

Answer 343

Metolazone (thiazide-like diuretic)

Question 344

CHF is most commonly caused by what two etiologies?

Answer 344

Coronary artery disease | Hypertension

Question 345

Consensus on using beta-blockers in CHF?

Answer 345

**admin of beta-blockers at high doses in acute CHF can worsen sx BUT, when titrated in small doses over weeks, can reduce sympathetic tone + reduce cardiac muscle remodeling *only use in NYHA Class II or III, EF

Question 346

Most useful test in diagnosing Alzheimers

Answer 346

MMSE with clock drawing | *neuroimaging and blood work is to rule out other cause

Question 347

What are the three drugs approved for tx of mild-moderate Alzheimers? What drug class/mechanism?

Answer 347

1. Donepezil (Aricept) 2. Galantamine (Reminyl) 3. Rivastigmine (Exelon) Mech: Acetylcholinesterase inhibitors (make ACh [which is reduced in Alzheimers] last longer in the synapse **improve sx but DO NOT slow down neurodegeneration

Question 348

What drug proven to have benefit in advanced Alzheimers? Drug class?

Answer 348

Memantine (Namenda) | NMDA receptor antagonist

Question 349

Diagnostic criteria for DM - Random glucose?

Answer 349

>=200mg/dL *****PLUS symptoms**** | *JUST NEED ONE MEASUREMENT

Question 350

Diagnostic criteria for DM - fasting glucose?Prediabetes?

Answer 350

>=126mg/dL (no caloric intake at least 8 hrs) * **NEED 2 DIFF MEASUREMENTS * 100-125 = prediabetes

Question 351

Diagnostic criteria for DM - 2-hr plasma glucose?Prediabetes?

Answer 351

>=200mg/dL (after 75g glucose load) * JUST NEED ONE MEASUREMENT * 140-200 =insulin insensitivity/prediabetes

Question 352

Diagnostic criteria for DM - A1C? Prediabetes?

Answer 352

>=6.5% | *5.7-6.5 = prediabetes

Question 353

Which lipid drug best for decreasing TGs?

Answer 353

Niacin * will also increase HDL and lower LDL BUT can increase insulin resistance * statins not as great at lowering TGs but some effect - always the best answer; can use in combination with niacin

Question 354

SGA vs IUGR

Answer 354

- SGA diagnosed at time of birth! Baby is less than the 3rd percentile to less than the 10th percentile for weight - IUGR diagnosed DURING pregnancy. Fetus has not reached its growth potential

Question 355

When in pregnancy do we screen for GBS?

Answer 355

35-37 weeks | *if +ve --> give peniciliin/ampicillin intrapartum prophylaxis

Question 356

When do we get APGARS (mins)?

Answer 356

1 min and 5 mins

Question 357

APGAR components

Answer 357

``` Appearance Pulse (palpate umbilical cord) Grimace Activity (muscle tone) Respiratory effort *Virginia Apgar :) ```

Question 358

Ballard assessment tool

Answer 358

uses signs of physical and neuromuscular maturity to estimate gestational age --> helpful if there is no early prenatal ultrasound to help confirm dates, or if the gestational age is in question because of uncertain maternal dates. http://www.medcalc.com/ballard.html

Question 359

What three complications are SGA newborns at risk for?

Answer 359

Hypothermia Hypoglycemia (from heat loss, poss hypoxia) Polycythemia (chronic hypoxia)

Question 360

TORCH infections

Answer 360

``` Toxoplasmosis Other (HIV, Hep B, syphilis, varicella-zoster, parvovirus B19) Rubella CMV Herpes *can see HSmegaly in all of these ```

Question 361

How do we test for TORCH infections (Hep B, Rubella, Toxo, CMV)? Incl whether sample comes from mom or baby

Answer 361

Hepatitis B - Maternal hepatitis B surface antigen (HBsAg) Rubella - Maternal and infant rubella titer Toxoplasma - Infant toxoplasma titer CMV - Infant urine culture

Question 362

We give erythromycin/tetracycline/silver nitrate eye antibiotics as prophylaxis against __?

Answer 362

Gonoccocal conjunctivitis! *though chlamydia conjunctivitis is more common, it typically occurs at 7–14 days after birth, and neonatal prophylaxis does little to prevent chlamydia conjunctivitis

Question 363

Three signs on CT of CMV infection in newborn

Answer 363

Intracranial calcifications Diminished number of gyri and abnormally thick cortex (= lissencephaly) Enlarged ventricles

Question 364

Main complications of congenital CMV

Answer 364

``` Developmental delay (think calcifications and lissencephaly) Hearing loss (progressive) ```

Question 365

Tx of congenital CMV

Answer 365

Parenteral ganciclovir or oral valganciclovir for 6 mos | Ideal if started in first month of life --> can help decrease progression of hearing loss

Question 366

Breastfeeding reduces maternal risk of what 3 paths?

Answer 366

Breast cancer Ovarian cancer Osteoporosis

Question 367

Why dont we give cows milk to infants? What age is it okay?

Answer 367

Risk of colitis --> microscopic bleeding! | Don't give cow's milk until 12 months

Question 368

Most babies lose a little weight right after birth. When is the latest time we expect them to atleast have regained their birth weight?

Answer 368

By 2 weeks old

Question 369

What is the caloric requirement of a healthy term baby per day?

Answer 369

100-120 calories/kg/day

Question 370

Average daily weight gain for a term infant (g)?

Answer 370

20-30g

Question 371

What is the caloric requirement of a preterm baby per day?

Answer 371

115-130 calories/kg/day

Question 372

What is the caloric requirement of a VLBW baby per day?

Answer 372

150 calories/kg/day

Question 373

What are the two most common rashes seen in newborns?

Answer 373

``` Neonatal acne (hormonal stimulation of sebaceous glands) Seborrheic dermatitis (cradle cap!) ```

Question 374

Earliest time babies can start eating solids?

Answer 374

4 mos (like cereals)

Question 375

Children should not sit in the front seat until age ___?

Answer 375

13yo | *ofcourse its really about height/weight requirements but age 13 is typically when these are met

Question 376

Car seats should face the rear until age ___?

Answer 376

2yo

Question 377

Which two vaccines are not given at all till 12mos?

Answer 377

MMR and HepA

Question 378

What 6 vaccines are given at the 2 month visit?

Answer 378

``` DTaP Hib IPV PCV13 RotaV HepB (2nd dose) *all rest are first dose ```

Question 379

By what ages should an infant double and triple his or her birth weight?

Answer 379

Double by 5 months, triple by 12 months

Question 380

Absence of a red reflex can indicate which 4 most common paths?

Answer 380

Cataracts Glaucoma Retinoblastoma Chorioretinitis

Question 381

How far away should you hold the fundoscope from the eye to evaluate red reflex in child?

Answer 381

10 inches

Question 382

Why is it not recommended to give prophylactic acetaminophen vaccinations?

Answer 382

Use of acetaminophen causes a lower antibody response for some immunizations *can give therapeutic if necessary

Question 383

Most commonly diagnosed cancer in infants?

Answer 383

Neuroblastoma painless mass in the neck, chest, or abdomen **small cell rosettes (Homer Wright) on path

Question 384

Beckwith-Wiedemann syndrome

Answer 384

Genetic overgrowth syndrome. Features: | omphalocele, hemihypertrophy, hypoglycemia, LGA, and other dysmorphic features

Question 385

Which cancer is commonly seen in Beckwith-Wiedemann syndrome (kids)

Answer 385

Wilm's tumor (abdominal mass that doesn't cross midline)

Question 386

Which of the bipolar medications need to be taken with food.

Answer 386

Geodan (ziprazodone), Latuda (lorazedone) | need at least 300-400 calories for the drug to be effcetive

Question 387

Which bipolar medication is FDA approved for acute mania?

Answer 387

Seroquel (quetiapine)

Question 388

side effect of theophyline

Answer 388

Tachycardia --> arrythmias

Question 389

What is the long acting therapy for chronic COPD (2)

Answer 389

LABA or LAMA (long acting muscarinic (anticholinergic)) (=tiotropium ie Spiriva)

Question 390

Who qualifies for the low dose spiral CT screening for lung cancer

Answer 390

``` Current smokers (or have quit within the last 15 years) aged 55 to 79 years old who have a smoking history of 30 pack-years or greater. [number of packs of cigarettes smoked per day by the number of years the person has smoked; 1 pack=20cigs] ```

Question 391

Sulfonylureas mechanisms of action? Examples?

Answer 391

Increase pancreatic secretion of insulin | Glypizide, Glyburide

Question 392

What are the 2 main mechanisms of action of biguanides? Examples?

Answer 392

1. Suppresses hepatic gluconeogenesis 2. Increases peripheral insulin sensitivity --> enhances peripheral glucose utilisation/uptake Example = METFORMIN

Question 393

Who do we screen for DM2? (3)

Answer 393

>=45yo BMI >=25 Pts with HTN

Question 394

DPP4 inhitors = orals for DM2 examples?

Answer 394

_gliptins (sitagliptin = JANUVIA)

Question 395

You newly diagnose pt with DM2. What are the steps in mgmt (Visit 1, 2, 3, if you check A1C and still not controlled)

Answer 395

Visit 1 - Lifestyle modification + metformin Visit 2 still uncontrolled - Add 2nd agent (no specific one is best! must choose based on preferences) Visit 3 - Start insulin

Question 396

Three contraindications to metformin

Answer 396

CKD (creatinine >1.5) CHF Liver disease *all bc of lactic acidosis

Question 397

Expected drop in A1C by oral meds vs insulin?

Answer 397

``` Orals = 3% at most (metformin) Insulin = 7% ```

Question 398

In what newly diagnosed patients do we jump straight to insulin as tx?

Answer 398

If A1C is >9% | *bc oral agents are not going to be enough to get them to goal

Question 399

Main risk with sulfonylureas?

Answer 399

Hypoglycemia | *remember, they increase pancreatic secretion of insulin so its almost like giving insulin

Question 400

Thiazolidinedione (TZDs) mechanisms of action? examples? side effects?

Answer 400

Increase insulin sensitivity | _glitazones --> pioglitazone, rosiglitazone

Question 401

Thiazolidinedione (TZDs) mechanisms of action? examples? side effects?

Answer 401

Increase insulin sensitivity Ex. _glitazones --> pioglitazone, rosiglitazone Side effects: WEIGHT GAIN

Question 402

What is our goal A1C for DM2 pts?

Answer 402

A1C

Question 403

What is our goal A1C for DM2 pts?

Answer 403

A1C

Question 404

Big three end organs DM2 goes after slash that we should screen every year

Answer 404

Eyes (retinopathy), kidneys (proteinuria/CKD), feet (peripheral neuropathy)

Question 405

Screening test for diabetic kidney damage?

Answer 405

Urinalysis: microalbumin:creatinine ratio

Question 406

What are the three long acting insulins (basal)

Answer 406

Lantus (glargine) Levemir (detemir) *both start with 'L'!! plus NPH (which has to be given BID unlike the above that are once)

Question 407

What are the three rapid acting insulins?

Answer 407

NovoLOG (aspart) HumaLOG (lispro) *both end in 'LOG' plus REGULAR INSULIN

Question 408

What are NovoLIN and HumaLIN ?

Answer 408

Mixed insulins! | ie. long acting (NPH) and short acting (Reg Insulin) combined

Question 409

How many units of long acting insulin do we give? When do they take it?

Answer 409

0. 1U/kg at BEDTIME | * but titrate based on patient's morning glucose --> until you get to goal or up to 50units

Question 410

Major side effect of the _glitazones

Answer 410

Fluid retention/edema

Question 411

If patient has angioedema with ACE inhibitor can you switch to an ARB?

Answer 411

No! There is crossreactivity so pt will likely still have it with ARB *unlike cough, where you can switch to an ARB

Question 412

Hypoglycemia blood sugar cut off?

Question 413

Tx for hypoglycemia if pt is awake vs coma?

Answer 413

Awake --> oral glucose (or some food/drink with rapid sugar) | Comatose --> IV D50

Question 414

Tmax of glucose in the kidneys?

Answer 414

180mg/dL

Question 415

What 4 tests to order to dx DKA?

Answer 415

BS --> 300-500 Urinalysis (or serum is better but takes longer) --> +ketones ABG --> acidosis BMP --> anion gap, K+

Question 416

In treating DKA, what 3 lab values do we need to continuously monitor

Answer 416

Glucose Anion gap K+

Question 417

How do we treat the high glucose in DKA?

Answer 417

IV insulin bolus | FOLLOWED BY continuous Insulin Drip

Question 418

What do you always need to check before you give insulin to pt in DKA? Values/mgmt?

Answer 418

Potassium! *remember if you give insulin, K+ shifts INTO cells, so if pt is already HYPOkalemic, you make it worse. If K+ give IV K+

Question 419

Remember, pts in DKA are going to be extremely dehydrated from osmotic diuresis from the high sugars. How do we tx the dehydration?

Answer 419

Vigorous rehydration! | BOLUS NS or LR

Question 420

Unlike DKA, pts with HHS won't present as acutely, but sugars will be higher = MORE dehydrated! BS values seen in HHS?

Answer 420

800-1000 | *they shouldn't have any ketones or acidosis!

Question 421

Tx for HHS?

Answer 421

Same as DKA = insulin +fluids | *only difference is you are not monitoring anion gap and reacting to it.

Question 422

According to USPSTF guidelines, who should be put on aspirin for primary prevention of CVD and colorectal cancer?

Answer 422

Adults 50 to 59 yo who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding

Question 423

Which patients need to be on a statin?

Answer 423

1. Vascular dz (CAD, MI, periph vasc dz) 2. LDL >=190 3. LDL 70-189, but have (1) DM, (2) AGE 40-75, (3) CVD risk factors (smoking, HTN, obesity) * only pts who dont get a statin = LDL

Question 424

We always want to put patients on a high intensity statin if possible (rather than mod or low intensity). What are the 2 high intensity statins?

Answer 424

Atorvastatin Rosuvastatin *both also available as moderate intensity (by giving lower dose)

Question 425

What are my three statins that are available as moderate and low intensity statins?

Answer 425

Simvastatin Pravastatin Lovastatin

Question 426

In which patients do we have to use a moderate intensity statin (as opposed to high intensity)? (4)

Answer 426

CKD Liver disease Age >75 Can't tolerate statin

Question 427

The 2 major side effects of statins

Answer 427

Muscle injury | Liver dysfunction

Question 428

What do you do if patient develops muscle injury or liver dysfunction from statin?

Answer 428

Stop the statin BUT once the event resolves, restart them on a lower dose.

Question 429

If we cant give a pt a statin, cholesterol drug that is best next in line? What do they lower/increase?

Answer 429

Fibrates Lower TGs, Increase HDL *also cause myositis/inc LFTs (like statins)

Question 430

Ezetimibe - What does it lower/increase? Side effect?

Answer 430

Only lowers LDL Side effect = diarrhea (bc they block cholesterol absorption from gut --> osmotic encoperesis) (all same as bile acid sequestrants)

Question 431

Niacin -- pathognomonic side effect and how to handle?

Answer 431

Flushing! | Prophylaxis with aspirin

Question 432

Niacin -- what does it increase/decrease?

Answer 432

Lowers LDL, Increases HDL | *sounds like the magic pill but doesn't actually work that well.

Question 433

First line tx for N&V in pregnancy?

Answer 433

Unisom (Doxylamine) + Pyridoxine (B6) * try diet/lifestyle modification first -- eating smaller, blander meals * doxylamine = first gen antihistamine

Question 434

Which type of calcium supplement good for patients with GERD on PPI?

Answer 434

Calcium citrate | *vs calcium carbonate which is cheaper, but needs stomach acid to be absorbed

Question 435

Ketorolac -- drug class? brand name?

Answer 435

NSAID | *Toradol

Question 436

New onset paralysis below T9 (or other spinal level) in diabetic?

Answer 436

Spinal epidural abcess --> get an MRI

Question 437

Antibiotic of choice for invasive (bloody) travelers diarrhea from Campylobacter

Answer 437

Azithromycin

Question 438

Antibiotic of choice for diarrhea from Entamoeba or Giardia?

Answer 438

Metronidazole

Question 439

Antibiotic of choice for diarrhea from Salmonella or Shigella?

Answer 439

Ciprofloxacin

Question 440

All NSAIDs except whic one have been proven to increase risk of MI?

Answer 440

Naproxen

Question 441

Tx for gonorrhea, with negative chlamydia test

Answer 441

Ceftriaxone (gono) + azithromycin or doxycycline (chl) | *still tx for the chlamydia even if test is negative!

Question 442

Preferred antibiotic for CAP in children 5yrs

Answer 442

5yo = azithromycin

Question 443

Signs of retinal vein occlusion (3)? commonly seen in what pt popltn? (2)

Answer 443

Sudden, painless loss/distortion of vision Tortuous veins on fundoscopic exam Cotton wool spots on fundoscopic exam *Think diabetics and HTN

Question 444

First line tx for keloids

Answer 444

Intralesional corticosteroid injection

Question 445

Four drugs that can cause false positives on opioid drug screen

Answer 445

Dextromethorphan diphenhydramine ibuprofen fluoroquinolones

Question 446

Proximal muscle weakness, elevated serum creatine kinase and aldolase, sx improve significantly with corticosteroids...?

Answer 446

Polymyositis (inflammatory myopathy)

Question 447

Which of the uterotonic drugs is contraindicated in postpartum hemorrhage in pt with HTN?

Answer 447

Ergot derivatives | *cause smooth muscle contraction including vessels

Question 448

First line therapy for ulcerative colitis?

Answer 448

Sulfasalazine | *make sure to also screen for colorectal cancer

Question 449

Tramadol (Ultram) contraindicated in patients with what history?

Answer 449

Seizures | *other drug same = Buproprion; lowers seizure threshold

Question 450

Spirometry cut off of FEV1/FVC ratio to qualify as COPD

Answer 450

FEV1/FVC ratio

Question 451

For patient on lithium monotherapy, monitoring labs should include (3) other than lithium trough?

Answer 451

- Creatinine, BUN - TSH (lithium can cause HYPOthyroidism) - Calcium (can cause HYPERcalcemia --> hyperparathyroidism)

Question 452

Bamboo spine

Answer 452

Appearance of lumbar spine on xray in ankylosing spondylitis

Question 453

Most common extraarticular manifestation of ankylosing spondylitis? tx?

Answer 453

Uveitis --> tx with steroids

Question 454

Pt with heel pain, on examination pain over medial plantar region of the heel, pain is aggravated by passive ankle dorsiflexion -> dx?

Answer 454

Plantar fasciitis | *do not need any imaging to confirm

Question 455

Doxycycline not used in kids

Answer 455

Teeth staining | Exceptions = anthrax, tick-borne diseases

Question 456

Between the two sulfonylureas (Glypizide v Glyburide), which one is more likely to cause hypoglycemia? why?

Answer 456

Glyburide more likely to cause hypoglycemia because it has a longer half life than Glypizide

Question 457

What is the preferred screening test for TB in pts who have received the bCG vaccine?

Answer 457

Interferon-gamma release assays (IGRA) | *too many false positives with the TST

Question 458

What finding is most specific for heart failure (lab or physical exam findings)?

Answer 458

S3 heart sound | more specific than BNP

Question 459

Two paths most commonly treated with hyperbaric oxygen with proven long term benefit

Answer 459

``` Decompression sickness (divers, nitrogen bubbles) Crush/severe wound injuries ```

Question 460

Likelihood ratio

Answer 460

= the likelihood that a given test result would be expected in a patient with the target disorder compared to the likelihood that that same result would be expected in a patient without the target disorder. *so if LR = 1, the test is crap, >1 means dz is likely,

Question 461

Which opioid is the only one metabolized in the liver, so safe to give pts with renal disease?

Answer 461

Fentanyl

Question 462

Giving corticosteroids to pregnant woman before delivery is beneficial only if given before ___ weeks?

Answer 462

34 weeks

Question 463

mech of action of _gliptins (ex Januvia)

Answer 463

Prolongs activity of endogenously released GLP-1 (gut derived hormone that stimulates insulin secretion/suppresses glucagon secretion, delays gastric emptying, & reduces appetite)

Question 464

Which is faster acting -- Aspart/Lispro vs regular insulin?

Answer 464

Aspart/Lispro (15-30mins) * vs regular insulin = 30-60 mins * good way to remember = synthetic ones doe everything better

Question 465

Which is longer acting -- NPH vs Lantus/Detemir?

Answer 465

Lantus/Detemir (24h) * vs NPH = 20 hrs * good way to remember = synthetic ones doe everything better

Question 466

Which test in the lipid panel (LDL, HDL, TGs. tot cholesterol) is most predictive of adverse outcomes?

Answer 466

Low HDL

Question 467

Smoking cessation will affect which of the values in the lipid panel?

Answer 467

Will increase HDL *smoking cessation incs it by 5-10 Exercise increases it by ~15

Question 468

What amount of induration is a positive TST in healthy individuals vs immunocompromised ex HIV

Answer 468

Healthy = 15mm | HIV, etc = 5mm

Question 469

We begin prophylaxis for PCP in HIV pts if CD4 count drops below what value?

Question 470

We begin prophylaxis for Mycobacterium avium complex (MAC) in HIV pts if CD4 count drops below what value?

Question 471

Tx for PCP?

Answer 471

TMP-SMX (+glucocorticoids if severe)

Question 472

Which one lifestyle modification is MOST beneficial in lowering systolic blood pressure?

Answer 472

Weight loss! | followed by DASH diet, followed by lowering sodium

Question 473

JNC8 tx guidelines for HTN - black pts

Answer 473

Thiazide (1st) or Ca Channel Blocker or BOTH | *thiazides in both black/nonblack BUT no ACEI in blacks

Question 474

JNC8 tx guidelines for HTN - NONblack pts

Answer 474

Thiazide (1st) or CCB or ACEI or combination

Question 475

JNC8 tx guidelines for HTN - pts with CKD

Answer 475

ACEI or ARB alone or in combo with other drug

Question 476

Pt with high blood pressure on cuff but weak femoral pulses?

Answer 476

Coarctation of aorta

Question 477

Newly diagnosed pt with HTN, what do we test for in serum?

Answer 477

Serum = electrolytes, glucose, creatinine, eGFR

Question 478

Newly diagnosed pt with HTN, what three other tests to run (other than serum)?

Answer 478

Lipids Urinalysis (hematuria, albumin/creatinine) EKG

Question 479

BMI classifications (4)

Answer 479

Underweight 30 (morbid >40)

Question 480

What value from a DEXA scan indicates osteoporosis?

Answer 480

T-score -2.5 or less | *ie. 2.5 or more std deviations below mean

Question 481

Bisphosphonates mech of action?

Answer 481

They bind to surface of bone and are eaten up by osteoclasts, and once inside they inhibit enzyme in the osteoclasts

Question 482

Two FDA approved drugs for PTSD

Answer 482

Sertraline (Zoloft) | Paroxetine (Paxil)

Question 483

Tx for acute mania (ex. after giving antidpressants to manic pt)

Answer 483

Antipsychotics! | *can use lithium, valproate, etc for maintenance

Question 484

Subclinical hypothyroidism criteria?

Answer 484

Elevated TSH but normal free T4 | *do not treat, continue to monitor, only 4-8% will progress to true hypothyroid

Question 485

Graves dz causes hypo or hyper thyroid?? mechanism?

Answer 485

Most common cause of HYPERthyroidism. Autoantibodies (IgG) STIMULATE TSH receptors on thyroid

Question 486

After fall, patient with pain out of proportion and tenderness with passive flexion of muscle, but normal appearing limb

Answer 486

Suspect compartment syndrome --> fasciotomy! *Before the classic findings develop “Five Ps” (pain, paresthesia, pallor, pulselessness, and paralysis) those are the signs

Question 487

Tx for GAS pharyngitis?

Answer 487

Penicillin | *Penicillin-resistant group A Streptococcus has never been documented

Question 488

Pt post camping trip, rash anywhere on the body, including the palms and soles, but the face is spared?

Answer 488

Rocky Mountain Spotted Fever

Question 489

First line pharm agents for managing hypotension in pt with sepsis v cardiogenic shock v hemorrhagic shock?

Answer 489

Sepsis = dopamine Cardiogenic shock = dobutamine Hemorrhagic shock = packed RBCs

Question 490

Pt with cancer, who now has hypostension and a ton of electrolyte abnormalities -- diagnosis? tx?

Answer 490

Adrenal crisis from mets to adrenals! | Tx = IV hydrocortisone

Question 491

elevated AST level in the absence of alcohol or drug-induced liver disease strongly suggests what path?

Answer 491

Nonalcoholic fatty liver disease (NAFLD)

Question 492

Best tx for NAFLD that reduces AST, but also improves liver histology?

Answer 492

Healthy diet, weight loss, and exercise

Question 493

Diabetes insipidus pathophys

Answer 493

Deficiency in the secretion or renal action of arginine vasopressin (AVP)=antidiuretic hormone --> profound urinary volume, increased frequency of urination, and thirst (but NORMAL sugars)

Question 494

Carnett's sign

Answer 494

Have patient lay supine, and raise their legs --> tenses abdominal wall muscles Positive = pain increases -- abd wall is the source of the pain (ex. hematoma is rectus sheath) Negative = pain decreases -- intrabdominal issue

Question 495

Mild cognitive impairment -- what is it? major risk factor?

Answer 495

intermediate stage between normal cognitive function and dementia Risk factor = APO E4 allele

Question 496

Personality disorders mnemonic for the clusters

Answer 496

Weird (A), Wild (B), Worried (C)

Question 497

Cluster A personality disorders (weird) (3)

Answer 497

Paranoid Schizoid Schizotypal

Question 498

Cluster B personality disorders (wild) (4)

Answer 498

Borderline Narcissistic Histrionic Antisocial

Question 499

Cluster C personality disorders (worried)

Answer 499

Avoidant Dependent OCD

Question 500

Tx for tinea capitis

Answer 500

Oral griseofulvin

Question 501

You have a pt with some signs worrisome of a PE or DVT, but very low risk. Next step in evaluation?

Answer 501

D-dimer * its a high SENSITIVITY test, so if its negative, you can trust pt doesn't have PE/DVT * if its +ve do CT for PE, US for DVT

Question 502

First line tx for neuropathic pain

Answer 502

TCAs or calcium channel alpha 2-delta ligands (gabapentin and pregabalin=Lyrica)

Question 503

Stillbirth is defined as fetal death occurring at or after __ weeks gestation?

Answer 503

20 weeks

Question 504

First-line drugs for essential tremor (2)

Answer 504

Primidone (anticonvulsant) and propranolol

Question 505

The threshold for transfusion of red blood cells should be a hemoglobin level of __ g/dL in adults and most children.

Answer 505

7 g/dL

Question 506

How do ACE inhibitors cause hyperkalemia?

Answer 506

Reduce aldosterone! (R-> A->A->S) | *recall aldosterone increases K+ excretion in principle & intercalated cells

Question 507

treatment of choice for menorrhagia due to endometrial hyperplasia without atypia?

Answer 507

Progestins | *cyclic oral medroxyprogesterone, given 14 days per month, or IUD

Question 508

Which of the child vaccinations does not have a catch up period?

Answer 508

Rotavirus

Question 509

Which bone in the hand is most commonly injured in a dorsiflexion injury/FOOSH?

Answer 509

Scaphoid

Question 510

First line drug for hypertension in pregnancy?

Answer 510

Labetalol

Question 511

Remember infectious endocarditis vegetation on the tricuspid valve likely to be seen in what pateints + by what bug?

Answer 511

IV drug users -- STAPH AUREUS

Question 512

Are corticosteroids better in treating Crohns or UC?

Answer 512

Crohns! = rule of c's | *UC benefits more from 5-ASA preps ex. sulfasalazine

Question 513

At what age do we start doing DEXA scans?

Answer 513

65yo | *or younger if pt has increased fracture risk

Question 514

Pneumonia caused by what microorganism starts off with nonspecific systemic symptoms (ex. high-grade fever, malaise, myalgias, anorexia, and headache) and are then followed by respiratory sx?

Answer 514

Legionella pneumophila

Question 515

chronic daily cough; thick, malodorous sputum, bronchial wall thickening and luminal dilation

Answer 515

Bronchiectasis

Question 516

Antidote to magnesium toxicity in pregnant woman with preeclampsia given mag infusion

Answer 516

Calcium gluconate

Question 517

FVC and FEV1/FVC changes in restrictive lung disease?

Answer 517

Reduced FVC with a normal or increased FEV1/FVC ratio | *contrast to asthma: reduced FEV1 and a decreased FEV1/FVC ratio

Question 518

Other than insulin, what other common drug increases potassium uptake into cells --> hypokalemia?

Answer 518

Beta-agonists (ex. albuterol)

Question 519

Red man syndrome is seen after infusion with what drug?

Answer 519

Vancomycin

Question 520

Antibody test for celiac disease?

Answer 520

IgA antiendomysial antibody

Question 521

Pts who are super tall (Men taller than 72in and women taller than 70in) + other manifestations suspicious for Marfans should get what screening?

Answer 521

Echo! | *high risk for cystic medial necrosis of the aorta --> look for aortic incompetence and dissecting aortic aneurysms

Question 522

When should children with bacterial conjunctivitis be allowed to return to school?

Answer 522

Once treatment is started

Question 523

Colonoscopy -- every 10 years if normal and no family hx. how often if fam hx of colon cancer?

Answer 523

q5 yrs

Question 524

How often should colonoscopy be repeated if benign polyps are found?

Answer 524

q3 yrs

Question 525

Best study for confirming the diagnosis of a urinary tract stone in a patient with acute flank pain?

Answer 525

helical CT scan of the abdomen and pelvis without contrast

Question 526

Side effects of lithium (4)

Answer 526

Postural tremor Polyuria/Thirst Weight gain Diarrhea

Question 527

List the 6 most common atypical antipsychotics with brand name

Answer 527

``` Clozapine (Clozaril) Olanzapine (Zyprexa) Risperdone (Risperdal) Aripiprazole (Abilify) Ziprasidone (Geodon) ```

Question 528

Rash seen in strep throat infection?

Answer 528

Scarlet fever *Punctate, erythematous, blanching, sandpaper-like rash found in the neck, groin, and axillae, and is accentuated in body folds and creases (Pastia's lines).

Question 529

To diagnose ADHD, must be at least ___ years old?

Answer 529

6 years old

Question 530

To diagnose ADHD, sx must be present before child is __ years old?

Answer 530

12 years old