Final Step Flashcards
A patient with HIV presents with severe groin pain. What is the most likely diagnosis?
Avascular necrosis of the femoral head. Antiretroviral medications put patients at an increased risk of AVN.
A 65 year old presents complaining of severe pain in his great toe that began when he woke up this morning. It is swollen, red and very tender. What is the most likely diagnosis?
Gout would be number one because of the location, but you might also think about an infection
Scleroderma limited version has five main characteristics for which the CREST acronym is often used. What are those five things?
Calcinosis, Raynaud’s, esophageal dysmotility, sclerodactyly, telangiectasia
Vasculitis with a hepatitis B history should make you think of what diagnosis?
polyarteritis nodosa
A patient presents with knee pain following a soccer game two days ago. He has joint line tenderness medially and feels a locking in the knee from time to time. What two physical exam tests should you do?
This is probably a medial meniscal tear. McMurry and Apley tests would be appropriate.
A positive Apley indicated what diagnosis?
meniscal tear
Which of the four rotator cuff muscles is most commonly injured?
supraspinatus
On physical exam, you notice ulnar deviations and swan neck deformities. What is the most likely diagnosis?
rheumatoid arthritis
What is the name for the 4th and 5th metacarpal fractures that often occur punching a wall.
Boxer’s fracture
A pathology report comes back with positive birefringent crystals. What is the most likely diagnosis?
pseudogout
A 15 year old boy presents complaining of night pain in the pelvis. Since you have no idea what to do, you order an x-ray. The report comes back with a description of a mass with an “onion skin appearance.” What is the most likely diagnosis?
Ewing sarcoma
What is the medical term for golfer’s elbow?
medial epiconylitis
What is the medical term for hunchback?
kyphosis
What is the age range for osteosarcoma? Where are thy most typically found in the body?
Osteosarcoma usually occur in 15-25 year old males and are most commonly found around the knee.
Where are Bouchard’s nodes found?
proximal interphalangeal joint (PIP)
Are most shoulder dislocations anterior or posterior?
anterior
What is the most common fracture in a patient with osteoporosis?
a compression fracture of a vertebral body followed by hip fractures
Which carpal bone has a high rate of nonunion and occult fracture?
scaphoid
A fat pad sign on a lateral x-ray of the elbow has what significance?
it is blood in the joint indicating a fracture even if the fracture line cannot be seen
What is the medical treatment for gout?
allopurinol, colchicine
A positive Phalen and Tinel’s sign indicates what diagnosis?
carpal tunnel
A pathology report comes back showing negatively birefringent crystals. What is the most likely diagnosis?
gout
What fracture is the #1 cause of compartment syndrome?
tibial shaft fracture
A positive Neer’s test indicated what diagnosis?
rotator cuff impingement
You suspect a patient has polyarteritis nodosa. What is the test for a definitive diagnosis and what is the treatment?
biopsy, high dose steroids
What are the four muscles of the rotator cuff?
Commonly referred to as the SITS muscles they are Supraspinatus, Infraspinatus, Teres minor, Subscapularis
What is the most useful physical exam test for diagnosis an ACL tear?
Lachman’s followed by anterior drawer
An African American female presents with malar rash and a positive double-stranded DNA antibody. What is the most likely diagnosis?
lupus
A positive straight leg test indicates what diagnosis?
herniated disc
What test do you do for Sjogren’s syndrome?
Schirmer test
Which way does a Colles fracture angulate: dorsal or volar? What about a Smith fracture?
Colles = Dorsal, Smith = Volar
What is a first line treatment for rheumatoid arthritis?
methotexate
What is the most common knee injury?
medial meniscal tear
What medication is used for patients with lupus?
systemic steroids
A new mother presents with pain over the radial wrist. She has a positive Finkelstein’s test. What is the most likely diagnosis?
de Quervain’s tenosynovitis
A positive Hawkins test indicated what diagnosis?
Rotator cuff impingement
At what age should you begin ordering DEXA scans for male patients? What about female patients?
70 for males, 65 for females
What is the medical term for tennis elbow?
lateral epicondylitis
Tenderness over the anatomical snuffbox is indicative of what fracture?
scaphoid
What is the first line treatment for carpal tunnel?
night splint
46 year old male comes into the ER limping a little on the right side. He states that it felt as though he was kicked in the back of the leg during a soccer game, but clearly no one was behind him. What is the most likely diagnosis?
Achilles tendon rupture
List three medication that may cause lupus.
procainamide, isoniazid, and quinidine
A patient’s lab work shows positive Smith antibody and positive double-stranded DNA antibodies. What is the most likely diagnosis?
Lupus
What is the most common cause of a hip dislocation? Is it usually anterior or posterior?
MVA, posterior
A 95 year old female presents to ER after a fall in her home. Her left leg is shortened and externally rotated. What is the most likely diagnosis?
hip fracture
What ligament is most commonly injured in an ankle sprain?
Anterior talofibular ligament (ATFL)
A patient with a history of hepatitis B presents complaining of bilateral knee pain, fever and weight loss. What is the most likely diagnosis?
polyarteritis nodosa
You recommend bisphosphonates for a patient with osteoporosis. What instruction do you give her for immediately after taking the medication?
remain upright for 30 minutes
A positive crossover test indicates what diagnosis?
acromioclavicular joint injury (AC joint)
A 22 year old male patient presents with what is a clearly a septic knee. He is unable to actively extend his knee. What is the most likely diagnosis?
Neisseria gonorrhoeae
A patient presents to the ER after taking a baseball bat to the knee. He is unable to actively extend his knee. What is the most likely diagnosis?
patella fracture
Where are Heberden’s nodes found?
distal interphalangeal joint (DIP)
What is the best imaging to diagnose osteomyelitis?
Bone scan or MRI
A patient with rheumatoid arthritis is heading to the OR for open reduction and internal fixation of the ankle. In addition to ankle films, what other x-rays should you get?
C-spine, anesthesia will want them due to concerns about instability of C1 and C2
A bamboo spine indicates what diagnosis?
ankylosing spondylitis
Anatomically where are 80% of clavicle fractures located?
middle third
A positive McMurry indicated what diagnosis?
meniscal tear
Anti-Jo 1 antibodies should make you think of what diagnosis?
polymyositis
A patient presents to the ER with saddle anesthesia and loss of bowel and bladder function. What is the most likely diagnosis?
Cauda equina
What would you expect the WBC count to be in the joint fluid of an infected knee?
> 50,000 at a minimum and probably much higher
A patient presents with a painless mass in her right wrist. What is the most likely diagnosis?
ganglion cyst
What will an x-ray show in acute osteomyelitis?
nothing - it will show bone destruction in chronic osteomyelitis
There is a sunburst appearance on x-ray. What is the most likely diagnosis?
osteosarcoma
You think a patient may have an osteoid osteoma due to his complaints of severe night pain. You set him up for an x-ray; but in the meantime what medication do you start him on?
If it is truly an osteoid osteoma ibuprofen will resolve his pain
A positive Finkelstein’s test indicates what diagnosis?
de Quervain’s tenosynovitis
Give the DEXA score for osteopenia and osteoporosis
osteopenia = 1 to 2.4 standard deviations, osteoporosis = 2.5 standard deviations or greater
Carpal tunnel affects what nerve and what parts of the hand?
Median nerve. Thumb, pointer and ring fingers, Thenar wasting is a sign of advanced disease
Patient presents with conjunctivitis, urethritis, arthritis and oral lesions. What is the most likely diagnosis? What other lab might you expect to be positive?
Reactive arthritis, HLA B-27
What is the most common fracture in children?
clavicle
Clicking or locking of the knee indicates what diagnosis?
meniscal tear
Describe the characteristics of a lytic lesion on x-ray.
spiculated, elevated periosteum, bone destruction (think bad, very bad things)
Patient presents with progressive neck and proximal muscle weakness. On physical exam, you see a reddish purple maculopapular rash. Her lab work shows an anti-Jo-1 antibodies. What is the most likely diagnosis?
polymyositis
A patient with a silver-fork deformity on x-ray. What is the most likely diagnosis?
Colles fracture
What is the most common cause of C-spine fractures?
motor vehicle accidents
What uric acid level helps to confirm a diagnosis of gout?
> 7.5
What is another term for podagra?
gout
A patient has a tremor with motion in his hands. What medication might you prescribe?
This patient has an active tremor therefore a beta blocker like propranolol is a good start
A patient complains of muscle weakness and fatigability that improves with rest. What diagnosis should you be thinking of?
Myasthenia gravis
A patient complains of an aching headache which feels like a band around his head. What diagnosis should you be thinking of?
Tension headache
An EEG showing focal rhythmic discharges at the onset of the seizure should make you think of what diagnosis?
Simple partial seizure
A middle age male presents with unilateral periorbital headaches occurring daily for several weeks. These headaches are extremely painful. Which type of headache is most likely cause?
Cluster headahce
Name one abortive drug for migraines.
Triptans (sumatriptan, zolmitriptan), ergotamine
What is the most common cause of dementia?
Alzheimer’s disease, it may be as high as 80%
Duchenne’s and Becker’s muscular dystrophy have what genetic characteristic?
X-linked recessive
What is the age range for Duchenne’s muscular dystrophy?
3-5 years old
A patient presents with lateralized throbbing headache. He is also complaining of nausea, vomiting, and photophobia. What type of headache is most likely?
Migraine
If CT is negative and you still believe there is a stroke what is the next best test to order?
Lumbar puncture
A patient presents with a painful ipsilateral third nerve palsy. What diagnosis should you be thinking of?
Posterior communication artery aneurysm (PComA)
Describe Kernig’s sign
The patient lies supine, flex hip while keeping knee straight. Back pain is positive
A patient presents following a seizure. Just before the seizure she remembers seeing flashing light all around her. What diagnosis should be at the top of your differential?
Complex partial
A patient presents to your office complaining of a tremor in his right hand. He states after a beer it goes away completely. What diagnosis should you be thinking of?
Benign essential tremor or familial tremor
Which nerve root is responsible for the knee jerk reflex?
L3-L4
What cranial nerve is affected with Bell’s palsy?
CN VII
What is the medical treatment for a stroke in which the CT has shown no evidence of a hemorrhage?
Within the first 4 hours and with no contraindications thrombolytics should be given
Alcohol may be a major factor in which encephalopathy?
Wernicke’s
Under what conditions would aspirin or clopidogrel be used following a TIA as prophylaxis?
These are antiplatelet medications. They would be used unless there is a known cardiac etiology for the embolism. Patients with a cardiac cause should use heparin or Coumadin.
An EEG showing generalized spikes and associated slow waves should make you think of what diagnosis?
Generalized or absence seizure
What is the medication of choice for a patient with Tourette’s syndrome?
Haloperidol
What are the most common primary cancer sties for metastasis to the brain?
Lung, breast, kidney
A patient presents with what appears to be an inability to understand speech. Which aphasia should be at the top of your differential?
Wernicke’s aphasia
At what age do symptoms of Huntington’s disease appear?
Around 30 years old
Wilson’s disease is associated with a build up of what mineral?
There is a deficiency of the copper binding protein and therefore a buildup of copper
A patient is brought in following a seizure in which she did not lose consciousness. What diagnosis should you be thinking of?
Simple partial seizure
Which is the most commonly herniated vertebral disc?
L4-L5 followed by L5-S1
A patient presents with signs of a stroke to the ER what is the most important test to get?
CT
A patient presents complaining of the worst headache of his life. What might you expect their blood pressure to be?
Typically this is the description for a subarachnoid hemorrhage. You would expect the blood pressure to be elevated.
A sudden thunderclap headache should make you think of what diagnosis?
Subarachnoid hematoma
Lead pipe or cogwheel rigidity should make you think of what diagnosis?
Parkinson’s disease
A 35-year old patient comes to your office because his wife made him. He has been increasingly irritable and moody. She has also noticed that he is very restless. You order a CT scan which shows cerebral atrophy as well as atrophy of the caudate nucleus. What diagnosis should you be thinking of?
Huntington’s disease
What percentage of strokes are ischemic? What percentage are hemorrhagic?
80%, 20%
Name three medications used to break a seziure?
Diazepam, lorazepam, phenytoin or fosphenytoin
At what percentage of blockage is an endarterectomy indicated?
asymptomatic >70%, symptomatic >60%
Elevated circulating acetylcholine receptor antibodies should make you think of what diagnosis?
Myasthenia gravis
A patient presents with inability to speak and right sided weakness. He seems to understand speech and follows commands well. What type of aphasia should you be thinking of?
Broca’s aphasia
What are the genetic characteristics of Wilson’s disease?
Autosomal recessive, chromosome 13
What four chromosome have been linked to dementia?
1, 14, 19, 21
Decreased GABA and substance P should make you think of what diagnosis?
Huntington’s
What is the defining symptom of Alzheimer’s?
Progressive memory impairment
List three medications used to “treat” multiple sclerosis?
Steroids, interferon beta, copolymer 1
A lumbar puncture for a patient with bacterial meningitis will show elevated or decreased WBCs? glucose? Protein?
Elevated WBCs, decreased glucose and elevated protein
Weakness and numbness in the left hand might be a blockage in which carotid artery?
Right
A resting or pill-rolling tremor should make you think of what diagnosis?
Parkinson’s disease
A patient has an intracranial neoplasms causing auditory illusions, olfactory hallucinations and emotional changes. What lobe is the lesion likely in?
Temporal
A study results comes back with intracellular neurofibrillary tangles and extracellular neuritic plaques. What diagnosis should you be thinking of?
Alzheimer’s disease
Is the ankle jerk reflex of lumbar or sacral origin?
Sacral
What is the most common cause of subarachnoid hemorrhage aside from trauma?
Ruptured cerebral aneurysm
List six medications that can be used for migraine prophylaxis?
Beta blockers, tricyclics, calcium channel blockers, NSAIDs, and valproic acid
There is an MRI result of multiple foci of demyelination in the white matter. What diagnosis should you be thinking of?
Multiple sclerosis
List three drugs that treat cluster headaches.
Oxygen, sumatriptan, butorphanol
A patient presents with weakness that he has felt in his lower legs and now feels in his knees and hip bilaterally. He has decreased deep tendon reflexes. This has been getting progressively worse. What diagnosis should you be thinking of?
Guillain-Barre
What three symptoms are classic for a normal pressure hydrocephalus?
Gait disturbance, dementia, and urinary incontinence
What is the most common primary intracranial neoplasm?
Glioma
A 34 year old presents with symptoms which are relapsing and remitting over the past few weeks. These include visual problems and weakness in her right arm. What is the most likely diagnosis?
Multiple sclerosis
List two medications you might use to treat an essential tremor.
Beta blocker (propranolol), primidone
Give two classes of drug therapy for treating Parkinson’s.
Dopaminergic (levodopa), anticholinergics are second line.
A shuffling gait should make you think of what diagnosis?
Parkinson’s disease
You believe a patient has had a stroke. He presents with aphasia, loss of hearing in one ear and loss of vision in his left eye. Is the blockage likely in the anterior or posterior circulation?
Anterior
What is the single most important thing to be concerned about with a patient in status epilepticus?
Airway, followed by management of hyperthermia
Is Huntington’s autosomal dominant or recessive?
dominant
What symptom is associated with a classic migraine?
Having an aura
An EEG showing interictal spikes should make you think of what diagnosis?
Complex partial seizure
Describe Brudzinski’s sign.
When you lift the patient’s head the patient bends his hips.
A slit lamp shows Kayser-Fleischer rings. What diagnosis should you be thinking of?
Wilson’s disease
What seizure medication may cause overgrowth of the gums?
Phenytoin
You are looking for lesions associated with multiple sclerosis. When you order an MRI do you order it with gadolinium or without?
With gadolinium
A patient presents with facial paresis, arm drift, and abnormal speech. What are the first three tests to order?
Thinking of a stroke you order a non-contrast brain CT or MRI, serum glucose, and oxygen saturation.
An 18 month old is not yet speaking. He does not point to objects. He does not make eye contact with others. What diagnosis should you be thinking of?
Autism
How is acute stress disorder different than posttraumatic stress disorder?
Acute stress disorder occurs within 1 month of event and resolves within about a month. PTSD begins at about 1 month after event and can last indefinitely.
During an interview a patient states “I have been anxious for as long as I can remember.” This statement should make you think of what diagnosis?
Generalized anxiety disorder
What is the term for being afraid of being out in a terrible situation with no help available?
Agoraphobia
What medication is clearly contraindicated in anorexia and bulimia?
Bupropion (Wellbutrin) because it can increase risk of seizures
How do you treat alcohol withdrawal?
Benzodiazepines
A patient expresses concern that he can’t trust anyone. That everyone is out to get him, and his problems are all the faults of others. He has help very long grudges due to perceived past wrongs. What diagnosis should you be thinking of?
Paranoid personality disorder
List the four cluster B personality disorders.
“Bad” antisocial, borderline, histrionic, and narcissistic
List the two cluster C personality disorders.
“Sad” avoidant and obsessive compulsive
What is the major concern with using lithium?
It has a very narrow therapeutic window. Blood tests are needed every four weeks.
What two psychiatric issues are more common in males than females?
Autism and ADD, the rest are all either equal or more common in females.
A patient has very strange magical thinking. What diagnosis should you be thinking of?
Schizotypal personality disorder
What causes anorexic patients to have osteopenia?
A decrease in estrogen
A doughnut shaped burn should make you think of what issue?
Abuse, either child or elder
What is necessary to diagnose a patient with bipolar 1?
One manic episode. They do not have to have the depressive episode for the diagnosis.
Are hallucinations normal during a grieving period?
Yes, as long as they are not persistent or intrusive
A patient exhibits all of the characteristics of antisocial personality disorder, but he is only 14 years old. What diagnosis should you be thinking of?
Conduct disorder
A patient complains of having suddenly developed stage fright. It is very important to his career that he is able to speak in front of groups. What medication might you treat with him with?
Beta blocker - propranolol
How long must symptoms occur before diagnosing schizophrenia?
At least six months
What is the term for a chronic mild depression which has lasted greater than two years?
Dysthymia
What type of behavioral therapy works best for borderline patients?
Dialectical behavior therapy
When is the typical onset of Tourette’s syndrome?
3-8 years old
Name three SSRIs.
fluoxetine, paroxetine, sertraline, citalopram, escitalopram, dapoxetine, zimelidine, mesembrine, seproxetine
Borderline personality disorder is on the border of what two psychological disorders?
Neurosis and psychosis
A patient believes that her 15 year old daughter is sleeping with the mailman. She has no evidence of this. She has confronted her daughter who denies it. It is not interfering with her daily activities, but she does spend time thinking about it. What diagnosis should you be thinking of?
Delusional disorder
A patient’s wife complains that he is hypervigilant and has a hyperstartle response. What diagnosis should you be thinking of?
Posttraumatic stress disorder
What is Russel’s sign?
Abraded knuckles from forcing oneself to vomit.
List four symptoms of serotonin syndrome.
Hyperthermia, seizure, mental status change, tremor
How long does menstruation need to be absent before secondary amenorrhea can be diagnosed?
If cycles have been previously normal: 3 months. If cycles have been previously irregular: 6 months.
What medication is often used to treat postpartum depression in a women who is breast feeding?
Sertraline (Zoloft)
What type of hallucinations are most common in schizophrenia auditory, visual, or olfactory?
auditory - hearing voices
What medication is a good place to start treating bipolar 1 or 2?
Lithium
List three positive symptoms of schizophrenia.
Hallucinations, delusions, movement disorder
How long before normal grief resolves?
About one year
A patient is arrogant with an inflated self image. He feels he is special and should be treated that way. What diagnosis should you be thinking of?
Narcissistic personality disorders
List the three cluster A personality disorders.
“Mad” schizoid, schizotypal and paranoid
To be diagnosed with ADD patients must exhibit symptoms before what age?
7 years old
How long must symptoms last before diagnosing ADD?
6 months
What is the generic name for Prozac?
Fluoxetine
A patient complains of acute paralysis in his left arm. This does not seem to bother him, but his wife made him come in. There was no traumatic event. A complete neurologic workup is negative. What diagnosis should you be thinking of?
Conversion disorder
A psychiatric patient presents with confusion, fever, and lead pipe rigidity. What diagnosis should you be thinking of?
Neuroleptic malignant syndrome, this can occur with high dose antipsychotics
Are patient with specific phobias aware they are strange?
Yes
What is the time frame from the fist symptom of withdrawal from alcohol?
Tremor in 8-18 hours
Is obsessive compulsive disorder egosyntonic or ego-dystonic? What about obsessive compulsive personality disorder?
OCD is ego-dystonic. OCPD is egosyntonic.
A spiral fracture should make you think of what issue?
Abuse, either child or elder.
How long does a panic attack typically last?
10-20 minutes
A patient exhibits splitting, seeing others as all good or all bad. What diagnosis should be thinking of?
Borderline personality disorder
A patient’s mother has recommended that he see you. He lives on his own and is a computer programmer. He works from home. He has no friends and seldom leaves the house. She is concerned that he expresses no interest in meeting people and seems perfectly happy to be home alone all the time. What diagnosis should you be thinking of?
Schizoid personality disorder
Waxy flexibility should make you think of what diagnosis?
Catatonic schizophrenia
Posturing should make you think of what diagnosis?
Catatonic depression
Antisocial personality disorder may not be diagnosed until what age?
18 years old
A patient is very concerned that she has breast cancer. In order to reassure her you perform a full workup which is negative. She is still unsatisfied and convinced that she has breast cancer. What diagnosis should you be thinking of?
hypochondriasis
Is anorexia egosyntonic or ego-dystonic? What about bulimia?
Anorexia is egosyntonic. Bulimia is ego-dystonic
When treating psychiatric patients are benzodiazepines used more commonly for acute or chronic treatment?
acute
A 6 year old boy seems to have all of the symptoms of ADD while at school, but at home he has no problems. Does he have ADD?
No, symptoms must occur in both settings for diagnosis
A patient’s mother has recommended that he see you. He lives on his own and is a computer programmer. He works from home. He has no friends and seldom leaves the house. She is concerned that clearly he would like to meet people, but is terrified of doing so. What diagnosis should be thinking of?
Avoidant personality disorder
A patient is very charming during his interview. You note during your interview that he has no concern for hurting or using other people. He seems to show no remorse for any of his actions. What diagnosis should you be thinking of?
Antisocial personality disorder
What is the most common precipitating event for posttraumatic stress disorder in women?
Rape
You have a patient with major depressive disorder. Once his symptoms have completely resolved how long should you continue with treatment?
A six month minimum is recommended due to very high relapse rates.
A 16 year old has just moved schools. He is quiet, moody, and not like himself at all. Within six months he seems to have completely changed back to his previous personality. What diagnosis should you be thinking of?
Adjustment disorder
What two things are needed to make a diagnosis of bipolar 2?
One major depressive episode and one hypomanic episode
A patient of yours always craves attention, often using sex as a tool to gain it. She often acts like a child when she does not get her way? What diagnosis should you be thinking of?
Histrionic personality disorder
At what BMI should a patient be hospitalized for anorexia?
BMI < 17.5 or 20% below appropriate body weight
A sawtooth pattern on EKG should make you think of what diagnosis?
Atrial flutter
List the 4 minor criteria for diagnosing endocarditis.
Fever, embolic event (Janeway lesions or petechiae, splinter hemorrhages), immunological event (Osler nodes, glomerulonephritis), 1 positive blood culture
List three class 1a antiarrhythmics.
Disopyramide, quinidine, procainamide
An RSR prime in leads V5 or V6 should make you think of what diagnosis?
Left bundle branch block
What is the first line IV inotropic agent when dealing with cardiogenic shock?
Dopamine
A blockage of which artery causes an anterior wall MI?
Left anterior descending artery
Following a myocardial infarction, what medication should you be using to treat hypertension?
Beta blocker
Tall peaked P waves should make you think of what diagnosis?
Right atrial enlargement
What is the best patient position to hear aortic regurge and aortic stenosis?
sitting up and leaning forward
An elderly patient presents with dyspnea, angina and syncope on exertion. The EKG is normal. What is the most likely diagnosis?
Aortic stenosis
Name one aldosterone antagonist.
Spironolactone, eplerenone
A patient has a GFR of 25 and HTN. Which class should you use, a loop or a thiazide diuretic?
A loop will work no matter how low the GFR is. Thiazides will only work with a GFR over 30.
After a thiazide diuretic, what medication should you start in a hypertensive patient who also has diabetes?
An ACEI or an ARB
Which EKG lead are used to diagnose an anterior wall MI?
V1, V2 and V3
Clot busting drugs should be used within 3 hours of which two cardiac events?
STEMI and new left bundle branch block
On an EKG, you notice a patient has a gradually lengthening PR interval and then a missed QRS complex. The pattern repeats again. What type of AV block is this?
Mobitz I or Wenckebach
Which hyperlipidemia medication may cause flushing?
Niacin
Any ulcers from venous insufficiency painful or painless?
painless
Where do most aortic dissections occur?
the ascending or descending thoracic aorta
What two labs do you want to monitor in a patient on an ACEI?
serum creatinine and serum potassium
What are the three major criteria for endocarditis?
2 positive blood cultures, a positive transesophageal echocardiography, new murmur
Where is disease of the pulmonary valve best heard?
2nd left intercostal space
A continuous murmur most likely involves what area of the heart?
It is most likely a septal defect
Where on your patient should you listen for the murmur associated with an atrial septal defect?
At the left second or third interspace
A patient recently started taking Lipitor. He is now complaining of aches and pains. What test should you order?
Serum creatinine kinase, you’re looking for rhabdomyolysis
A patient complains of severe pleuritic chest pain that is relieved with sitting and leaning forward. What is the most likely diagnosis?
Pericarditis
An EKG shows two premature ventricular contractions. These two QRS waves look very different. What is the term for this?
Multifocal premature ventricular contractions
On EKG there is an early but otherwise normal PQRS complex. After that beat there is a slight pause and then a normal rhythm continues. What is the term for this one beat?
Premature atrial contraction
What side effect might make a patient stop taking an ACEI?
Cough
On physical exam, you hear a harsh systolic murmur along the right sternal border. What is the most likely diagnosis?
Aortic stenosis
An RSR prime in leads V1 or V2 should make you think of what diagnosis?
Right bundle branch block
A patient has just received a cardiac stent. How long will he be on aspirin and clopidogrel?
One year
A beta natriuretic peptide below what level rules out CHF?
< 100
Define orthostatic hypotension
A drop in systolic blood pressure of > 20 mmHg when standing up
Which EKG leads are used to diagnose an anterolateral MI?
V5 and V6
What two leads do you use to determine the axis of the heart?
Lead I and AVF
What medication might you switch to if a patient develops an intolerable cough on an ACEI?
Angiotensin receptor blocker (ARBs)
Bat wing vessels or Kerley B lines on a CXR should make you think of what diagnosis?
CHF
Both lead I and AVF have positive QRS complexes. Does this represent normal axis, left axis deviation, or right axis deviation?
normal axis
What is the first line medical treatment for torsades de pointes?
Magnesium sulfate
What is the first line medical treatment for pericarditis?
Aspirin and NSAIDs
What is the appropriate treatment for a patent ductus arteriosus.
Indomethacin
What is the first line medical treatment for stage 1 hypertension?
Thiazide diuretic
Does a patient with mitral valve prolapse require prophylactic antibiotics for dental work?
No, a recent change moves mitral valve prolapse from high risk to moderate risk
What is the best test for diagnosing CHF?
Echo
Which lab should be tightly monitored in a patient taking an aldosterone antagonist?
Potassium, they may have hyerkalemia
In a patient with aortic stenosis, will the PMI be medially displace, normal or laterally displaced?
It will be laterally displaced due to left ventricular hypertrophy
Statins are the drug of choice to treat what type of dyslipidemia?
Elevated LDL
Name two things that would constitute a positive stress test.
A drop in blood pressure, a new arrhythmia, an increase in angina symptoms, ST depressions
A patient with mitral valve prolapse will often have what physical characteristics?
Often a thin female
An 82 year old patient complains of headaches and jaw claudication. What is the most likely diagnosis?
Giant cell (temporal) arteritis
What are the three inferior leads?
II, III, and aVF
The EKG shows irregularly irregular narrow QRS waves. What is the most likely diagnosis?
Atrial fibrillation
How do you treat polymyalgia rheumatica?
Low dose prednisone
Which cardiac medication has gynecomastia in its side effect profile?
Spironolactone
Lead I has a QRS that is up and the AVF lead has a QRS complex that is down. Does this represent normal axis, left axis deviation or right axis deviation?
Left axis deviation
Are most pulmonary valve problems congenital or acquired?
95% are congenital
You feel a pulse that seems to be vibrating. What term do you use to describe it?
Thrill
Where is disease of tricuspid valve best heard?
Along the left lower sternal border
What is Tietze syndrome?
Costochondritis
What is the most important complication of giant cell arteritis?
Blindness
What is the most common congenital heart disease?
Ventricular septal defect
List three medications which may be used for pharmacological stress testing.
Adenosine, dobutamine, dipyridamole and persantine
An EKG shows a regular heart rate of 200 bpms. QRS is narrow. What is the most likely diagnosis?
Supraventricular tachycardia
A U wave on EKG should make you think of what diagnosis?
Hypokalemia
Tall peaked T waves should make you think of what diagnosis?
Hyperkalemia
What is the best way to diagnose an aortic dissection?
CT
Rheumatic fever most commonly affects which valve?
The mitral valve
A patient complains of pain in his legs when he walks. It goes away after sittings. What term comes to mid for this symptom? What diagnosis is it associated with?
Intermittent claudication caused by peripheral arterial disease
What is the treatment goal for a diabetic with hypertension?
130/80
A question stem includes an IV drug user with a new heart murmur and fever. What is the most likely diagnosis?
Endocarditis
How does ezetimibe work?
Decreases intestinal absorption of cholesterol
A question about Prinzmetal’s angina will often contain what key thing in the patient’s history?
Cocaine use
Which are painful and found on the fingers and toes, Osler nodes or Janeway lesions?
Osler nodes
What is the definitive treatment for a patient with recurrent ventricular tachycardia?
Implanted defibrillator
Who is more likely to have an aortic aneurysm males or females?
Males are eight times as likely to have an aortic aneurysm
No matter what medications you use you are having trouble keeping a patient’s blood pressure under control. You also noticed hyperpigmented skin and truncal obesity. What is the most likely diagnosis?
Cushing’s disease
What is the only cyanotic congenital heart disease on the NCCPA blueprint?
Tetralogy of Fallot
A young boy comes into your office. He has elevated blood pressure when taken in his arm, but no femoral pulses can be palpated. What is the most likely diagnosis?
Coarctation of the aorta
What is the most common cause of sudden death?
Ventricular fibrillation
How do you define 1st degree AV block?
The PR interval is longer than 0.2 seconds or one block on EKG
List three congenital heart diseases.
Atrial septal defect (ASD), ventricular septal defect (VSD), coarctation of the aorta, patent ductus arteriosus (PDA), tetralogy of Fallor
A blockage of which artery causes a lateral wall MI?
left circumflex artery
List the six P’s of an ischemic limb.
Pain, paresthesias, pallor, pulselessness, poikilothermia, paralysis
What ejection fraction is typical for a patient with CHF?
35-40%
The accessory pathway known as the James bundle should make you think of what syndrome?
Lown-Ganong-Levine syndrome
What will a CXR show for a patient with an aortic dissection?
Widened mediastinum
A 60 year old male presents to the ER with severe dizziness and back pain. His blood pressure is dropping, and you can feel an abdominal pulsatile mass on physical exam. What is the most likely diagnosis?
Ruptured aortic aneurysm
What medication calls is used to lower triglycerides?
Fibric acid derivatives
On EKG, there is an early wide QRS complex with no associated P wave. After that beat, there is a slight pause, and then a normal rhythm continues. What is the term for this one beat?
Premature ventricular contraction
List three side effects of digoxin.
Nausea/vomiting, anorexia, confusion, arrhythmias (sinus brady, AV block), fatigue, vision disturbances etc.
You hear a loud, hard pulmonary murmur along the left sternal border. What is the most likely diagnosis?
Ventricular septal defect
You are counting boxes from the peak of a QRS wave on an EKG in order to determine the heart rate. What would the heart rate be if the next QRS wave peak were three boxes away? What numbers are associated with the first five boxes?
The answer is 100. The heart rates by counting boxes are 300, 150, 100, 75, 60.
What is the treatment for giant cell arteritis?
High dose prednisone
What is the most common cause of secondary hypertension?
Chronic kidney disease
What is the initial treatment for a myocardial infarction?
MONA - morphine, oxygen, nitroglycerin and aspirin
What is the first line medication for a patient with symptomatic bradycardia?
Atropine
You see regular P waves and regular QRS complexes, but you do not seem to have any correlation to each other. What is the diagnosis?
Third degree AV block
What is the best location to hear problems with the aortic valve?
2nd intercostal space
What is the gold standard for diagnosis of giant cell arteritis?
Biopsy of the temporal artery
If you hear a midsystolic click you should immediately be thinking about what diagnosis?
Mitral vale prolapse
A wide pulse pressure with a blowing diastolic decrescendo murmur at the right 2nd intercostal space should make you think of what diagnosis?
Aortic regurgitation
What terms will likely be include in a description of a patient with a pheochromocytoma?
Thin, diaphoretic, tachycardic, agitated
Do loop diuretics causer hyperkalemia or hypokalemia?
Hypokalemia
A boot-shaped heart on CXR should make you think of what congenital heart condition?
Tetralogy of Fallot
A patient presents to the ER in acute CHF. What drug class will likely be the first choice?
Loop diuretics
On auscultation, you hear a hard blowing pansystolic murmur at the apex. What is the most likely diagnosis?
Mitral regurgitation
Define pulsus alternans.
EKG waveform changes from beat to beat
What is the treatment for a patient with a Mobitz II AV block?
Pacemaker
List two risk factors for an aortic dissection?
Hypertension, Marfan’s syndrome, bicuspid aortic valve, pregnancy
You see a short PR interval and a delta wave on EKG. What is the most likely diagnosis?
Wolff-Parkinson-White syndrome
Which finding requires immediate attention: left bundle branch block or right bundle branch block?
New left bundle branch block is at STEMI equivalent, Right bundle branch block is usually not a problem.
What is represented by ST segment depressions greater than 1 mm on EKG?
Ischemia
What is the gold standard for diagnosing myocarditis?
Myocardial biopsy
What is the therapeutic range for INR following an organic valve replacement?
2 to 3
Name a common cause of a junctional rhythm.
Digitoxin toxicity
Calf pain should always make you think of what diagnosis?
DVT
What are three things in your differential if you have a paradoxical pulse?
Cardiac tamponade, pericarditis, and pulmonary obstructive lung diseases (think COPD)
What is the name of the syndrome that involves pericarditis several days after a myocardial infarction?
Dressler’s syndrome
What is the most common cause of CHF?
Coronary artery disease
A patient in the ER has no pulse; but on EKG, there are wide irregular “complexes” which are at an irregular rate. They all appear very different from one another. What is the treatment for this patient?
He is in ventricular fibrillation. The treatment is defibrillation
A biphasic P wave should make you think of what diagnosis?
Left atrial enlargement
What is the management of a patient in supraventricular tachycardia?
Vagal maneuvers, carotid massage, adenosine
What class of cardiac medications should be avoided in patients with asthma?
Beta blockers (blocks receptors for bronchodilators)
What is the most common cause of sudden cardiac death?
Ventricular fibrillation
What is the other term for Mobitz type I?
Wenckebach
Giant cell arteritis is associated with what other disease?
Polymyalgia rheumatica
Subacute endocarditis is most commonly caused by what organism?
Strep Viridans
An Osborn or J wave on EKG should make you think of what diagnosis?
Hypothermia
What is the most common cause of an atrial septal defect?
Patent foramen ovale
What is the definitive treatment for cardiac tamponade?
Pericardiocentesis
List the components of Virchow’s triad.
Stress, vascular injury, hypercoagulability
On palpation, what size is normal for the aorta?
Less than 3 cm
A CXR shows a “3” sign with notching of the ribs. What is the most likely diagnosis?
Coarctation of the aorta
What will the heart rate be if the AV node is pacing the heart?
40-60 beats per minute
What lab results will increase the risk of digoxin toxicity?
hypokalemia or hypercalcemia
The heart rate is irregular, so you can’t count boxes between QRS waves to determine heart rate. What is another method you can use to determine rate on an EKG?
Count QRS waves in a six second strip and multiply by 10 to get beats per minute
Give two contraindications for using an ACEI.
Bilateral renal artery stenosis, history of angioedema, pregnancy
A patient presents to the ER with tearing chest pain radiating to his back. What is the most likely diagnosis?
Aortic dissection
What is the accessory pathway associated with Wolff-Parkinson-White syndrome?
The bundle of Kent
What is the most likely diagnosis for a young man who experiences sudden death while playing sports?
Hypertrophic cardiomyopathy
Paroxysmal nocturnal dyspnea should make you think of what diagnosis?
CHF
List three catastrophic complications of a myocardial infarction.
Papillary muscle rupture, myocardial wall rupture and left ventricular aneurysm
Acute endocarditis is most commonly caused by what organism?
Staph aureus
An opening snap on auscultation of the heart should make you think of what diagnosis?
Mitral stenosis
You have a patient with diagnosis of a pheochromocytoma. While waiting for surgery, should you use an alpha blocker or a beta blocker?
Alpha blocker. Never use a pure beta blocker.
What is the most common place for an aortic aneurysm?
In the abdomen and below the renal arteries
You hear a continuous machine-like murmur. What is the most likely diagnosis?
Patent ductus arteriosus (PDA)
A patient complains of severe crushing chest pain. EKG shows ST segment elevations. All labs including troponins and CK-MB are negative. What is the most likely diagnosis?
Prinzmetal’s angina
Define paradoxical pulse.
There is a large difference in pulse pressure between inhalation and exhalation
You suspect mitral regurgitation. What is the most accurate way to prove your diagnosis?
Transesophageal echo
Which cardiac medication is used to help with cardiac contractility after you have optimized most of the other cardiac medications?
Digoxin
What is the gold standard for diagnosing coronary artery disease?
Cardiac catheterization
Are ulcers from arterial insufficiency painful or painless?
Painful
What are the five components of teratology of Fallot?
Ventricular septal defect, right ventricular hypertrophy, right ventricular outflow obstruction (pulmonary valve stenosis), overriding aorta, right sided aortic arch
List two diagnoses which require antibiotic prophylaxis for “dirty procedures”?
prosthetic valve, valve repair with any prosthetic material, prior endocarditis diagnosis, congenital cyanotic heart defect
What are the two main causes of aortic stenosis?
Congenital bicuspid valve and calcification of the valve secondary to coronary artery disease
An EKG shows a regular rate of 50 beats per minute. The QRS is narrow and there is no visible P wave. What is the most likely diagnosis?
Junctional rhythm
Where is disease of the mitral valve best heard?
At the apex
What is the definitive treatment for atrial flutter?
Radiofrequency catheter ablation
A patient presents to the ER with chest pain. An EKG shows diffuse ST elevations in almost all of the leads. What is the most likely diagnosis?
Pericarditis
List two cause of right atrial enlargement.
Pulmonary HTN, severe lung disease, pulmonary valve stenosis
A pathologic S3 is most commonly associated with what diagnosis?
CHF
According to the CDC, what is the range for a normal BMI?
18.5-24.9
You have a patient with pulsus paradoxus. What two diagnosis should you be thinking of?
Cardiac tamponade, pericarditis, pulmonary obstructive lung diseases (think COPD)
A fixed or consistent split S2 should make you think of what diagnosis?
Atrial septal defect
What two antibiotics are used for empiric treatment of endocarditis?
Vancomycin and ceftriaxone together are first line empiric treatment
A Blalock procedure is used to correct what congenital heart condition?
Tetralogy of Fallot
What imaging needs to be done before taking a patient to the OR with an aortic aneurysm?
CT (echo may be used as initial study, but CT is need for surgery)
What two valvular issues do patients with Marfan’s syndrome often have?
Aortic regurgitation and mitral valve prolapse (you can tell them apart by where they are heard)
Name three medication “classes” which are used to reduce LDL?
Statins, ezetimibe, niacin and nicotinic acid
Define stage 1 hypertension according to JNC 7.
Systolic pressure of 140-149 and diastolic of 90-99
What is the heart rate for tachycardia? How about bradycardia?
Tachycardia > 100, bradycardia < 60
The term satellite lesion should make you think of what diagnosis?
Candida diaper rash
Salmon-colored scales should make you think of what diagnosis?
Psoriasis
What are the ABC’s of melanoma?
Asymmetry, border, color, diameter, elevation/irregularity, evolving
Pitting nails are associated with what dermatologic disorder?
Psoriasis
What are the two most common organisms responsible for cellulitis?
Strep and Staph
A herald patch should make you think of what diagnosis ?
Pityriasis rosea
How do you treat pityriasis rosea?
Reassurance
Coin-shaped plaques should make you think of what diagnosis?
Nummular eczema
What is the best lab test for scabies?
Microscopic examination under oil immersion
Honey-colored crusts should make you think of what diagnosis?
Impetigo
What is the treatment for seborrheic keratosis?
It is benign so there is no need to treat it. Lesions may be removed if unsightly
Are lesions from psoriasis typically found on flexor or extensor surfaces?
Extensor
How do you treat lichen simplex chronicus?
Get the patient to stop scratching it
Extremely pruritic lesions with burrows in runs should make you think of what diagnosis?
Scabies
How do you treat a stasis dermatitis?
Compression stockings
A patient with a history of herpes now presents with a target lesions. What is the most likely diagnosis?
Erythema multiforme
A teardrop lesion after a course of strep throat should make you think of what diagnosis?
Guttate psoriasis
Why should actinic keratosis be treated?
It may progress to squamous cell carcinoma
What dermatologic finding is associated with insulin insensitivity?
Acanthosis nigricans
Depigmented patches of skin should make you think of what diagnosis?
Vitiligo
Spaghetti and meatballs on KOH prep should make you think of what diagnosis?
Tinea versicolor
What dermatologic finding is associated with asthma?
Atopic dermatitis
A patient presents with flaky skin in the nasolabial folds and on her scalp. What is the most likely diagnosis?
Seborrheic dermatitis
Tapioca blisters should make you think of what diagnosis?
Dyshidrosis - these are usually on hands and feet
Nummular eczema is most like what other dermatological disorder?
Atopic dermatitis
How do you treat dyshidrosis?
Topical steroids
What is the first step in treating atopic dermatitis?
behavioral modifications - reduce bathing, only use soap on face and genitals, use natural breathable fabrics
What two human papillomaviruses are most responsible for condyloma acuminata?
HPV 6 and 11
What is the treatment for melanoma?
Wide local excision
Where are 90% of basal cell lesions found on the body?
On the head and neck
What is the first line treatment for rosacea?
Metronidazole, tetracycline is probably a close second
Rhinophyma should make you think of what diagnosis?
Acne rosacea
Melasma is most often found in what patient population?
Women of childbearing age
What is the best treatment for molluscum contagiosum?
It is self limiting, but can be removed if patient really wants it
What is the first line treatment for tinea corporis
Topical azoles
A waxy stuck on appearance should make you think of what diagnosis?
Seborrheic keratosis
A Christmas tree pattern should make you think of what diagnosis?
Pityriasis rosea
A positive Auspitz sign should make you think of what diagnosis?
Psoriasis
A 30 year old female presents with pustules on her face that spare the vermillion border. In her history she has been using topical steroids. What is the most likely diagnosis?
Perioral dermatitis
Hyperpigmented velvety plaques should make you think of what diagnosis?
Acanthosis nigricans
Purple, pruritic, polygonal, papules on physical exam should make you think of what diagnosis?
Lichen planus
Oval patches of hair loss should make you think of what diagnosis?
Alopecia areata
What is the key indicator for the prognosis of melanoma?
Thickness of the lesions
A pearly dome-shaped lesions with a central umbilication should make you think of what diagnosis?
Molluscum contagiousum
Giant cells on a Tzanck smear should make you think of what diagnosis?
Herpes simplex virus
A 5 year old presents in early January with a red itchy rash behind his knees. You notice it on the flexor surfaces of his elbows as well. What is the most likely diagnosis?
Atopic dermatitis
Silvery scales should make you think of what diagnosis?
Psoriasis
What is the first line treatment for genital warts?
Imiquimod (Aldara)
A slowly growing nodule with central depression and a pearly border should make you think of what diagnosis?
Basal cell carcinoma
What is the treatment for a bad brown recluse spider bite?
Debridement, the venom causes tissue necrosis
A double comedone is indicative of what diagnosis?
Hidradenitis suppurativa
Large doughy hands should make you think of what diagnosis?
Gigantism
Cortical adrenal insufficiency is also known as what disease?
Addison’s disease
How do glitazones work?
They improve insulin sensitivity
Pretibial myxedema should make you think of what diagnosis?
Graves’ disease
In Cushing’s disease is ACTH elevated or decreased?
Elevated
In a patient with hyperthyroidism will TSH most likely be elevated or decreased?
Decreased
Positive antithyroid peroxidase and antithyroglobulin antibodies should make you think of what diagnosis?
Hashimoto’s
What is the test to begin with if you suspect a pheochromocytoma?
24 hour urine for catecholamines
Stocking glove anesthesia should make you think of what diagnosis?
Diabetic neuropathy and B12 deficiency neuropathy
Which thyroid cancer is the most aggressive?
Anaplastic
How do sulonylureas work?
They stimulate the produce of insulin
What is the most common thyroid cancer?
Papillary, makes up about 80% of thyroid cancers
How does levothyroxine work?
It is a synthetic T4
What heparin complication is relevant to endocrinology?
Adrenal infarct leading to a Cushing’s syndrome
How often should a diabetic’s HgbA1c be checked and what should it be?
Every three months (remember the life of an RBC is 90-120 days) and it should be below 6.5%
What role does C-peptide play in the diagnosis of diabetes?
It is a marker of insulin production. Elevated C-peptide points to DM 2. Decreased C-peptide points towards DM 1.
During pregnancy which is the preferred treatment of hyperthyroidism PTU or methimazole?
PTU
List four diagnostic criteria for diabetes?
Random glucose > 200, fasting glucose >126, two hour postprandial glucose > 200, HgA1c > 6.5%
What percentage of diabetes in the US is type 2?
80-90%
A 35 year old female presents with heat intolerance, weight loss, and palpitations. What diagnosis should you be thinking of?
Hyperthyroidism
Diabetes insipidus is caused by a deficiency of which hormone?
Vasopressin
Fruity breath should make you think of what diagnosis?
Diabetic ketoacidosis
List the 5 insulins in order of peak efficacy?
Lispro 1-2 hours, Regular 2-4 hours, NPH 5-7 hours, Lente 4-8 hours, Ultralente 8-14 hours
List 4 physical exam findings of Cushing’s syndrome.
Moon face, buffalo hump, purple striae, central obesity, supraclavicular fat pads, easy bruising
What medication class does metformin (Glucophage) fall into?
Biguanide
How do statins work to affect the lipid profile?
They slow the rate limiting step of cholesterol synthesis
What is the treatment for Addison’s disease?
Hydrocortisone or prednisone
Propranolol belongs to what class of medication?
Beta blockers
HLA-DR gene is a marker for what endocrine disorder?
DM type 1
What is the main function of parathyroid hormone?
Increase serum Ca
Is metformin indicated or contraindicated in renal failure?
Contraindicated
What is the best imaging for a thyroid nodule?
Ultrasound
What medication might you use prior to a thyroidectomy in a patient with hyperthyroidim?
Methimazole or propylthiouracil (PTU)
What lipid medication may cause flushing?
Niacin
What is the most common pituitary adenoma?
Prolactinoma
What is Graves’ disease?
The most common cause of hyperthyroidism. It is an autoimmune disease
What is the first line medical treatment for a patient with palpitations and nervousness secondary to hyperthyroidism?
Beta Blockers
What is the least aggressive thyroid cancer?
Papillary
Moans, groans, stones and bones describe symptoms of what endocrine problem?
Hyperparathyroid
How do fibrates work to affect the lipid profile?
They inhibit synthesis of ALDL and elevate lipoprotein lipase
Hyperpigmentation of the skin along creases should make you think of what diagnosis?
Addison’s disease
What is Trousseau’s sign?
Inflate BP cuff and hold for 3 minutes. Patient will low Ca will get carpal tunnel symptoms
What is the most common cause of hypoparathyroid?
Post thyroidectomy with complication of parathyroidectomy
What is Chvostek’s sign?
Tap on facial nerve and get a twitch with low Ca