Foils

Question 1

Rocky Mountain spotted fever

Answer 1

Tick bourne
Ricekettsia rickettsia
April September (Spring)
Children < 15
Southeast US
Fever, HA, myalgia
Small pink macule –> petechiae, purpura wrists/ankles –> trunk (spares face)
Normal WBC, left, shift, mild anemia, moderate thrombocytopenia, hyponatremia
Tx: doxycycline
Complications (due to vasculitis) - DIC, loss of limbs, CNS, lungs, kidneys

Question 2

Guillain-Barre

Answer 2

Auto-immune demyelination
30-40 y/o
Weakness (progressive ascending), areflexia, paresthesia
Often preceded by viral illness
Associated with campylobacter and flu vaccine
Loss of DTRs
Respiratory failure can develop
Autonomic instability (vs tick paralysis)
CSF: increased protein
Tx: admit, airway support, plasmapheresis, IVIG

Question 3

Strychnine

Answer 3

Rodenticide - white, odorless, bitter crystalline powder
Muscle spasms
Seizures, mydriasis, exophthalmos, nystagmus
Tachycardia, HTN, tachypnea, SOB, cyanosis, trismus, risus sardonicus, opisthitonus
Tx: supportive

Question 4

Henoch-Schonlein Purpura (HSP)

Answer 4

Immune mediated vasculitis (most common acute vasculitis affecting children)
Age 2-11, whites, winter, male
Preceding strep or GI infection (salmonella, shigella)
Abdominal pain (colicky, ileoilial intussusception), GI bleed, hematuria, palpable purpura (dependent areas, extensor surfaces), migratory large joint arthritis
4-6 week illness
Tx: supportive, steroids if renal manifestations (40%)
Normal platelets and coags

Question 5

Ransons criteria

Answer 5

GLOWS - glucose > 200, LDH > 350, older age > 55, WBC > 16, SGPT (AST) >250
BOB CHF - base defecit > 4, pO2 < 60, calcium < 8, BUN increase > 5, Hct drop > 10%, fluid deficit > 6L

Question 6

Jones criteria

Answer 6

GABS
3-4 weeks after infection
Major: migratory polyarthritis, carditis, subQ nodules (back of wrist, elbow, front of knees), erythema marginatum, sydenham chorea
Minor: fever, arthralgia, history of RF, prolonged PT, elevate ESR/CRP, GABS infection

Question 7

Diptheria

Answer 7

Club shaped gram + bacillus
Respiratory droplets
** pseudomembrane** exotoxin-induced necrosis
“Bull neck”
Heart (myocarditis), CNS (neuropathy), kidneys, liver
Tx: equine serum diphtheria antitoxin + erythromycin/PCN
Give antibiotics to carriers

Question 8

Pertussis

Answer 8

Bortadella pertussis - toxin mediated
URI, 2 wks (catarrhal phase) –> 2-4 weeks paroxysmal coughing spasms (inspiratory whoop only 1/3rd), post-tussive emesis followed by milder cough for months
Adults = primary reservoir, children = greatest risk
Vaccine
Mucous plugs, secondary bacterial infections, increased intrathoracic pressure (rectal prolapse, ruptured diaphragm, hernias)
Tx: erythromycin, TMP/SMX, isolation
Chemophrophylaxis for household contacts

Question 9

Babesiosis

Answer 9

Tick bourne
Hemolytic anemia
Tx: atorvaquone + azithromycin

Question 10

CO poisoning

Answer 10

Leading cause of toxic death
Shifts oxyhemoglobin dissociation curve to the left (inhibits release of O2 from Hgb)
Colorless, odorless
Incomplete combustion of fuel
Scenarios: cooking with grill without ventilation, car engine in enclosed space, furnace
HA, nausea, confusion, coma, sz, no cyanosis
Looks like “flu” but no fever and dog is sick too
Crosses placenta
Pulse Ox normal, PaO2 normal, measure carboxyhemoglobin (levels don’t predict toxicity)
1/2 life: 5 hours (RA), 1.5 hours (100% O2), 20 min (HBO) - may prevent delayed neuropsychiatric syndrome

Question 11

Hydrogen sulfide poisoning

Answer 11

Scenarios: oil refinery, hot asphalt, sewage, mines
Rotten egg odor
Tx: remove from source, 100% oxygen, methylene blue in cyanide antidote kit –> binds to methemoglobin

Question 12

Brown-Sequard

Answer 12

Unilateral cord injury
Penetrating trauma
Crossed below level of injury
Ipsilateral weakness and loss of position/vibration
Contralateral loss of pain/temp

Question 13

Erythema nodosum

Answer 13

Painful, non-ulcerative on anterior tibias, arms, trunks
Drug reaction, systemic infection (TB/fungal), sarcoid, IBD, malignancy
Common in women 30-50 y/o
Resolves in 3-6 weeks

Question 14

Crohns disease

Answer 14

Full thickness wall involvement (mouth to anus)
“skip lesions”
Gross blood < 50%
Granulomatous
Fistula formation
Increase oxalate absorption leads to calcium oxalate –> kidney stones

Question 15

Ulcerative colitis

Answer 15

Colon involvement (not small bowel), continuous
Blood diarrhea
Toxic megacolon
Mucosal and submucosal layers only (not full thickness)
Risk of colon cancer increases 30 fold

Question 16

Behcets disease

Answer 16

Vasculitis - diffuse involvement
Eyes - uveitis
Mouth - aphthous ulcers
Skin - pustules/folliculitis
Lung aneurysms --> lung hemorrhage
Joints - arthritis
CNS - headaches, confusion, strokes, personality changes, aseptic meningitis
Genitals - painful ulcers
GI - ulcers from mouth to anus (similar to Crohns)

Question 17

Juvenile Rheumatoid arthritis (JRA)

Answer 17

Pain, swelling, morning stiffness > 6 weeks
Fever, LAD, trunkal rash
Uveitis, growth problems

Question 18

Carcinoid syndrome

Answer 18

GI tumors: small bowel, appendix, stomach, colon, liver (or lung)
Secretes serotonin, prostaglandins
Skin flushing, diarrhea, hypotension, vasodilation, edema, ascites, bronchoconstriction
Tx: octreotide

Question 19

Hypokelemia periodic paralysis

Answer 19

Hereditary: autosomal dominant
Avoid high-carbohydrate/sodium diet
Thyrotoxicosis: young Asian males, onset after exercise
EKG changes: decreased Twaves, U wave, ventricular dysrhythmias
Replete both K (orally) and Mg + beta-blocker

Question 20

SLE

Answer 20

Female, African-american, multi-organ autoimmune
Fever, joint pain, rash
Butterfly facial rash (malar)
Discoid lupus: scaly, raised plaques on face, head, neck
Renal: nephritis, proteinuria, nephrotic syndrome, CRF
Cardiac: pericarditis, myocarditis, effusions, tamponade
Pulm: pleural effusions, pleurisy, pneumonitis, infarcts:
GI: oral and nasal lesions, GI vasculitis
Heme: anemia, thrombocytopenia, auto-splenectomy thrombosis
Neuro: sz, CVA, psychosis, migraines, neuropathy, transverse myelitis
Dx: ANA (most sensitive), anti-dsDNA (most specific)
Tx: severe with steroids

Question 21

Sarcoidosis

Answer 21

Non-infectious, non-caseating multi-system granulomatous disease
African-american adult females
Bilateral *hilar adenopathy, pulmonary infiltrates, ocular and skin lesions (waxy violacious papules)
*Hypercalcemia, anemia, eosinophilia, elevated ACE
Tx: steroids

Question 22

Dressler’s syndrome

Answer 22

Pericarditis 2-8 wks post-MI
Fever, leukocytosis, friction rub, pericardial and pleural effusions
Tx: NSAIDs, +/- steroids

Question 23

Kawasaki Disease

Answer 23

Mucocutaneous LN syndrome
Age 2-5, males, Asian
Major criteria (fever > 5 days + 4): bilateral conjunctiva, strawberry tongue/fissured lips, desquamation of swelling of fingers/toes, erythematous rash (starts on palms/soles), enlarged cervical LNs
Minor criteria: elevated WBC, elevated ESR, elevated platelets
coronary artery aneurysms
Tx: aspirin, IVIG

Question 24

Rubeola

Answer 24

3 C’s - cough, coryza, conjunctivitis
Koplick spots: buccal mucous (before rash), non-tender, tiny white spots (“grains of salt”
Maculopapular, moribilliform rash, head –> feet
Complications: encephalitis, PNA, OM, conjunctivitis
Not a TORCH infection

Question 25

Roseola

Answer 25

Human herpes virus (HHV) 6 Ages 6 -18 months High fever (3-4 days), then rash with defervescence Febrile seizures common Paint macules/papules on truck --> neck, face, extremities

Question 26

Temporal arteritis

Answer 26

Headache (85%), impaired vision (50%), jaw claudication Age >50 ESR > 50 Afferent pupillary defect Pale/erythematous optic disc Tx: ophthalmology consult, high-dose steroids, IV methylprednisolone if ocular symptoms < 48 hours

Question 27

Central Retinal Artery Occlusion (CRAO)

Answer 27

``` Sudden, painless, monocular visual loss Afferent pupillary defect Pale retina, fixed, dilated pupil "Cherry red spot" in the macular "Box car" retinal artery Mostly embolic Ophtho consult + CVA work-up Tx: lower IOP, gentle massage, increase PaCO2 (rebreathe in bag), acetazolamide (carbonic anhyrase inhibitor), timoptic ```

Question 28

Pheochromocytoma

Answer 28

Tumor of adrenal medulla (secretes norepinephrine) Dx: 24 hour urine catecholamine and metabolites (VMA) 20-44 y/o 5 Ps: Pressure, pain, perspiration, palpitations, pallor Tx: alpha- plus beta-blocker (ie labetalol + phentolamine)

Question 29

Osler-Weber-Rendu syndrome

Answer 29

Autosomal dominant Herediatary hemorrhagic telangiectasia Nosebleeds

Question 30

CREST syndrome

Answer 30

``` Calcinosis Raynaud's phenomenon Esophageal dysmotility Scelerodactyly Telangiectasia Chronic systemic autoimmune diorder ```

Question 31

Raynaud's phenomenon (disease = underlying cause)

Answer 31

3 criteria: precipitated by cold/emotion, bilateral, < 2 years, minimal to no gangrene Triphasic attacks Benign course - tx; reassurance

Question 32

ITP

Answer 32

Immune or idiopathic Low platelets Pediatric version: peak age 5, sudden onset petechiae/purpura several weeks after infectious illness, resolve within 6 months, no tx Adult: insidious onset/chronic/mostly women, transfuse at 20-30K or 30-50K with active bleeding, tx: steroids --> replace to 50K, high-dose Rho-GAM (anti-D immune globulin

Question 33

TTP

Answer 33

Severe decrease in platelets Severe microangiopathic hemolytic anemia with red cell fragmentation (shistocytes, helmet cells, fragmented RBCs) *Transient neuro deficits* Renal failure Fever Like DIC - damage to endothelial cells release von Willebrand factor and consumption thrombocytopenia --> small emboli --> end-organ ischemia Causes: idiopathic, drug-induced, pregnancy, infection Tx: steroids, plasmapheresis, FFP ** AVOID TRANSFUSING PLATELETS**

Question 34

HELLP syndrome

Answer 34

``` Variant of preeclampsia Multigravida Hemolysis, Elevated LFTs, Low Platelets Epigastric/RUQ pain Hemolysis: schistocytes Tx: bedrest, delivery, Mg, control BP, no diuretics or ACE inhibitors ```

Question 35

Horner's syndrome

Answer 35

Ptosis, miosis (constricted pupil), and anhydrous From unopposed parasympathetics Causes: carotid disease (dissection, aneurysm, trauma) or tumor (neck, lung)

Question 36

Rhabdomyolysis

Answer 36

Skeletal muscle injury Trauma, crush, burns, electrical injury, taser, heat stroke, ETOH, drugs) Causes acute tubular necrosis (myoglobin clogs tubules) Positive heme dip but no RBCs on micro CK > 5 times normal Elevated Cr Tx: IV hydration, treat hyperkalemia and hypocalcemia, alkalinize urine with bicarb

Question 37

Neuroleptic Malignant Syndrome

Answer 37

Antipsychotics Onset within 2 weeks of starting - slow onset (vs serotonin syndrome) FEVER: fever, encephalopathy, VS instability, elevated CPK, **rigidity ("lead pipe") vs serotonin syndrome (myoclonus) Tx: dantrolene or bromocriptine

Question 38

Trichinosis

Answer 38

Raw/undercooked pork N/D/V - first 1-8 days *periorbital edema, edema, muscle pain, fever, weakness CNS Not contagious Tx: antihelmentics - mebendazole/albendazole

Question 39

Dengue fever

Answer 39

``` Mosquito vector (Aedes aegypti) Flu-like - fever, HA, muscle/joint pain (bone breaking fever), moribilliform rash 80% asymptomatic 3-14 day incubation (usually 4-7 days) Hemorrhagic fevers Tx: supportive ```

Question 40

Tick paralysis

Answer 40

Rapidly ascending paralysis (like Guillain-Barre) but no paresthesias Tx: remove tick

Question 41

Ehrlichiosis

Answer 41

1-2 weeks after tick bite - flu-like symptoms Bacterial infection Tx: doxycycline

Question 42

Botulism

Answer 42

Food-borne, wound, infant (floppy baby, constipation, feeble cry) Neurotoxin blocks acetylcholine release --> impairs motor and autonomic function N/V/D *Bulbar symptoms - diplopia, ptosis, dysphagia, dysphonia, dysarthria --> D's diplopia, droopy eyelids, dilated pupils, dysarthria, dysphonia *Descending flaccid paralysis *Anticholinergic symptoms - dry mouth, urinary retention, dilated pupils ileum, decreased tears Tx: antitoxin, wound --> debridement, PCN

Question 43

Tetanus

Answer 43

Clostridium tetani (anaerobi gram + bacillus) Neurotoxin Risk: > 24 hours old, crush injury, devitalized tissue, burns, IVDA, early postpartum, soil Muscle spasm, rigidity, rises sardonic, opisthotonus, fever < 3 prior immunizations Tdap + TIG Minor > 10 years give Tdap Other wounds > 5 years give Tdap

Question 44

Wernicke/Korsakoff

Answer 44

Thiamine (vit B1) deficiency Encephalopathy, nystagmus, ophthalmoplegia (esp lateral rectus), ataxia, short-term memory problems Korsakoff --> amnesia, confabulation Tx: admission, thiamine (give before dextrose), magnesium

Question 45

Normal pressure hydrocephalus

Answer 45

``` "Wet, wacky, wobbly" Urinary incontinence, progressive dementia, ataxia CT: enlarged ventricles, no atrophy LP: opening pressure not elevated Tx: shunt ```

Question 46

Acoustic neuroma

Answer 46

Schwannoma - benign tumor fo the myelin forming cells of CN VIII Sudden hearing loss

Question 47

Marfan's syndrome

Answer 47

Collagen vascular disorder | Risk of spontaneous PTX and aortic dissection

Question 48

Osteogenesis imperfecta

Answer 48

Children: blue sclera, flaccid joints Frequent fractures, growth retardation Misdiagnosed as child abuse Fractures usually stop after adolescence

Question 49

Paget's disease

Answer 49

Disorder of bone recycling | Causes hypercalcemia

Question 50

Multiple sclerosis

Answer 50

Demyelination of multifocal areas 30s, F > M Optic neuritis: unilateral, central vision loss, pain with eye movement of papilliitis, loss of color *bilateral internuclear ophthalmoplegia = can't look at nose MRI (plaques), LP (increased protein, increased IgG, oligoclonal bands) Tx: steroids, plasma exchanges, disease modifying agents

Question 51

Eaton-Lambert

Answer 51

Similar to myasthenia gravis Auto-immune, effects calcium channels, failure to release acetylcholine Weakness/fatigue of proximal muscles (improves with use) Decreased DTRs Tx: remove tumor (50%, esp lung CA), plasmapheresis Avoid: neuromuscular blocking agents, ahminoglycosides, IV contrast, CCBs

Question 52

Optisthotonus

Answer 52

Severe hyperextension and spasticity Tetanus Strychnine toxicity Prussic acid (hydrogen cyanide) toxicity

Question 53

Phentolamine

Answer 53

Non-selective alpha-blocker (caused more reflex tachycardia)

Question 54

MAOI (phenelzine)

Answer 54

Blocks degradation of catecholamines 6-12 hours post ingestion: HA, HTN, tachycardia Hypertensive crisis: amphetamines, cheese, wine, lava beans (tyramine) Contraindicated: meperidine and dextromethorphan --> severe hyperthermia Tx: phentolamine + labetalol

Question 55

Serotonin syndrome

Answer 55

SSRIs: fluoxetine (Prozac, Sarafem), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil) Rapid onset (vs NMS): AMS, coma, sz, hyperthermia tachycardia, HTN, *myoclonus (vs NMS - "lead pipe"), hyperkinesia Tx: cooling, cyproheptadine

Question 56

Tensilon (edrophonium)

Answer 56

Increases acetylcholine by blocking breakdown of acetylcholine by cholinesterase --> increase muscle strength Can cause bradycardia and syncope --> tx: atropine

Question 57

Physotigmine

Answer 57

Treatment for refractory anti-cholinergic toxicity (except TCA) ("Hot as hell, blind as a bat, dry as a bone, red as a beet, mad as a hatter") - dry, flushed, dilated pupils (mydriasis), decreased bowel sounds, urinary retention Antihistamines, atropine, TCA, phenothiazines, antiparkinsonian drugs, Jimsonweed

Question 58

Myasthenia gravis

Answer 58

Auto-antibody to acetylcholine receptors Women (20-30 y/o) > men (50-60 y/o) 25% thymoma Bulbar symptoms - muscle weakness and fatiguability with diplopia and ptosis Limb weakness proximal > distal Worsens with use Precipitants: infection, fever, stress, AE medication Dx: anti-acetylcholine receptor Abs, tensilon test, ice pack test Tx: pyridostigmine or neostigmine Respiratory distress: exacerbation vs cholinergic crisis

Question 59

Amyotrophic Lateral Sclerosis (AML)

Answer 59

Degeneration of upper and lower motor neurons Muscle wasting, *fasciculations, *spasticy Weakness, difficulty eating and swallowing Dx: EMG Lower motor disease (anterior horn): atrophy, fasciculations Slowly progressive Death 2/2 respiratory failure

Question 60

Hemophilia A, B

Answer 60

A (factor VIII deficiency): most common (85%) B (factor IX): 15% Both are x-linked recessive Bleeding sites: joints, soft tissue (neck, airway, retroperitoneal), extremities (compartment syndrome), mucocutaneous (mouth, GI, nose), CNS (ICH most common cause of death), GU (hematuria), bone cysts from resolved hematoma Normal PT, increased PTT, decreased factor VIII or IX Tx: desmopressin (causes release of VWB factor --> allows extra factor VIII to be carried into plasma) - increases levels 3x within an hour, factor VIII replacement

Question 61

Von Willebrand disease

Answer 61

Most common inherited coagulation disorder VWB factor facilitated platelet activation and adhesion and carries factor VIII in the plasma PT normal, prolonged bleeding time, PTT increased Tx: desmopressin, factor VIII concentrate

Question 62

PT

Answer 62

Measures extrinsic pathway | Prolonged due to: warfarin, liver disease, Vit K deficiency, DIC

Question 63

PTT

Answer 63

Measures intrinsic pathway | Prolonged due to: heparin, hemophilia A/B (factor VIII, IX), VWB disease, lupus anticoagulant

Question 64

Direct thrombin and Factor Xa inhibitors

Answer 64

Indication: non-valvular atrial fibrillation Dabigatran (Pradaxa) - 80% renal excretion, tx: idarucizumab Rivaroxaban (Xarelto) - 35% renal excretion Apixaban (Eliquis) - 37% renal excretion

Question 65

G6PD deficiency

Answer 65

Genetic disorder common in males, African-American Causes hemolytic anemia Jaundice, pallor, splenomegaly Precipitated by: certain foods (fava beans)/medications (quinine, ASA, NSAIDs, sulfa, quinolones, nitrofurantoin), infections, stress

Question 66

Coombs test

Answer 66

Tests for globulin antibodies on the surface of RBCs | Dx for acute hemolytic transfusion reaction

Question 67

Sickle cell vasocclusive crisis (sludging causes obstruction)

Answer 67

Ischemic musculoskeletal pain (most common) Abdominal pain (2nd most common) Acute chest (leading cause of sickler death and 2nd most common cause of hospitalization, most common < 21 y/o) *Mycoplasma and Chlamydia pneumoniae CNS crisis Renal: infarct, hematuria, plank pain, papillary necrosis Hand-foot syndrome Priaprism: tx exchange transfusion, corpus cavernous epic and aspiration Splenic sequestration (2nd most common cause of death): tx RBCs and exchange transfusion Aplastic crisis: precipitated by infection, low folate Infections: pneumococcus , salmonella, H flu, staph, E coli, Mycoplasma - also influenza and parvovirus *Vaccinate

Question 68

Boutonnierre deformity

Answer 68

Central slip of extensor tendon

Question 69

Cholinergic toxidrome

Answer 69

"SLUDGE and the killer Bs" Salivation, Lacrimation, Urination, Diarrhea, GI upset, Emesis, Bradycardia, Bronchospasm, Bronchorrhea Miosis Nicotinic effects: muscle weakness, fasciculations, respiratory failure or :DUMBBELS": diarrhea, urination, miosis, bronchorrhea, bradycardia, emesis, lacrimation, salivation/sweating Causes: organophosphates, insecticides, mushrooms, chemical warfare Tx: atropine and 2-PAM (treat until dry secretions)

Question 70

Turner syndrome

Answer 70

2 in 1000 female US births Short stature, subbed neck, lymphedema, low hairline, low-set ears, sterility, shield-shaped thorax, *coarctation of the aorta, *bicuspid aortic valve, horseshoe kidney, visual impairment, learning disabilities, micrognathia Risk of aortic dissection 100-fold increase in females

Question 71

Vit B 12 deficiency

Answer 71

Macrocytic anemia | Neurologic signs/symptoms

Question 72

Medical/organic vs functional/psychiatric psychosis

Answer 72

"MADFOCS" Memory - recent vs distant impairment Activity - slow, tremor, ataxia vs repetitive Distortion - VH vs AH Feelings - labile vs flat Orientation - disoriented vs oriented Cognition - wax/wane vs inattentive, continuous Symptoms - age > 40, sudden, abnormal VS, immodest, aphasic vs age < 40, gradual, normal VS, modesty intact, intelligible

Question 73

Indications for CPAP

Answer 73

Mod-severe dyspnea + accessory muscle use Respiratory rate > 25 bpm Mod-severe acidosis pH < 7.35 Hypercapnia PaCO2 > 45

Question 74

Acute fatty liver of pregnancy (AFLP)

Answer 74

Late pregnancy Malaise, N/V, abdominal pain, *jaundice (vs HELLP) Hypoglycemia, low bilirubin, hypofibrinogenemia, ascites, encephalopathy

Question 75

Hanta virus

Answer 75

Rodent droppings Prodromal fever, severe body aches, abdominal pain, N/V/D Capillary leak --> ARDS/pulmonary edema --> cardiopulmonary phase Dx triad: thrombocytopenia, left shift, immunoblasts > 10%

Question 76

Lyme disease

Answer 76

``` Borrelia bergdorferi (First 1-2 months) erythema migrans, fatigue, HAs, arthralgia, abdominal pain (also CN palsies, ophthalmic conditions, carditis, meningitis) Late sequela (weeks to months later): joint, neurologic, cardiac (heart block) complications Dx: doxycycline (cefuroxime, amoxicillin) 2-3 weeks ```

Question 77

Features of typical pneumonias

Answer 77

Strep: lobar, rusty sputum H flu: COPD/smoker, lobar/patchy Staph: HCAP (includes MRSA), post-viral, patchy/multilobar, abscess/cavities, fumigating/necrotizing Klebsiella: diabetics, alcoholics, lobar, bulging right UL, current jelly sputum Anaerobes: aspiration, neurologic compromise, patchy, dependent lobes, abscesses Pseudomonas: HAP, cystic fibrosis, immunocompromised, patchy, multi lobar, sickly sweet odor, abscess, effusion

Question 78

Features of atypical PNA (don't show up on gram stain)

Answer 78

Mycoplasma: "walking", young adults, patchy, interstitial, extrapulmonary symptoms (bullies myringitis, hemolytic anemia, Guillain Barre, erythema multiform, cold agglutinins, encephalitits, relative bradycardia) Chlamydia: "walking", young adults, 3-20 wk old infants, staccato cough, conjunctivitis, relative bradycardia Legionella: old men with COPD, summer & winter, contaminated A/C, GI symptoms, not contagious, hyponatremia Fungal: not contagious, subacute -- coccidiomycosis (SW US), blastomycosis (SE US), Histoplasmosis (Mississippi valley) --> fluconazole Exotic: Q fever (sheep/cow, hepatitis, endocarditis), psittacosis (parrot, epistaxis, headache, tetracycline), hanta virus (rodents, SW US, hemorrhage)

Question 79

Meniere's (idiopathic endolyphatic hydros) vs labrynthitis

Answer 79

Hearing loss, tinnitus, vertigo vs hearing loss, tinnitus, vertigo ++ post-viral ++

Question 80

SLE criteria

Answer 80

4 out of 11 1) malar rash 2) discoid rash 3) photosensitivity 4) oral ulcers 5) non erosive arthritis 6) pleurites or pericarditis 7) renal disorder (proteinuria or casts) 8) neurologic disorder (seizure or psychosis) 9) hematologic disorder 10) immunologic disorder (anti-dsDNA or anti-Sm) 11) positive ANA

Question 81

Acute radiation sickness

Answer 81

lymphocyte count >1200 = less severe 3.5 Gy exposure = lethal Background radiation = 3.6 mSV N/V/D within a few hours

Question 82

Addison's disease

Answer 82

Chronic adrenal insufficiency (primary) Fatigue, weightloss Hyponatremia, hyperkalemia (hypoNa, hypoglycemia) Skin pigmentation ACTH stimulation test ACTH level high/normal in primary adrenal insufficiency (adrenals not functioning) vs low in secondary (pituitary not functioning)

Question 83

Lhermitte sign

Answer 83

Flexion of neck causes electric shocks down spine | Seen in MS, cervical myelopathy/radiculopathy, tumor, Fit B12 deficiency

Question 84

Oculovestibular reflex

Answer 84

"COWS" - intact brainstem cold opposite, warm same | If brainstem function lost = tonic deviation towards irrigation

Question 85

Hypocalcemia

Answer 85

Chvostek sign - tapping cheek | Blood pressure spasm

Question 86

Tumor lysis syndrome

Answer 86

Hyperkalemia, hyperphosphatemia, **hyperuricemia, hypocalcemia --> tetany, hyper-reflexia

Question 87

Acid-base disturbances

Answer 87

``` Metabolic acidosis (low HCO3) with compensatory hyperventilation (low pCO2) Metabolic alkalosis (high HCO3) with compensatory hypoventilation (high pCO2) (ie, volume contraction, vomiting, diuretics) Respiratory acidosis (high pCO2) with compensatory increased renal absorption (high HCO3) (ie hypoventilation) Respiratory alkalosis (low pCO2) with compensatory decreased renal absorption (low HCO3) (ie anxiety, mechanical ventilation, CNS disease) ```

Question 88

Non-gap metabolic acidosis

Answer 88

HARDSUPS Hyperventilation, Acetazolamide, renal tubular acidosis, diarrhea, ureteral diversion, pancreas, spironolactone Most common = diarrhea, spironolactone

Question 89

Adrenal insufficiency

Answer 89

Primary: Addison's, congenital adrenal hyperplasia Secondary: pituitary (decreased ACTH) Tertiary: hypothalamic (decreased corticotropin releasing factor) Primary symptoms: shock, abdominal pain, fever, hyperglycemia, hyperpigmentation, fatigue (chronic), weightloss (chronic) Secondary symptoms: no hyperpigmentation, hypotension, hyponatremia, hypoglycemia, less GI

Question 90

Amebiasis

Answer 90

Entamoeba histolytica Fecal-oral transmission Liver abscesses = non-surgical, bacterial superinfection uncommon Alk phos and AST/ALT elevated Tx: metronidazole 750 mg TID x 1 week --> paromomycin/iodoquinol/diloxanide furoate

Question 91

Anterior cord syndrome

Answer 91

Loss of motor, pain/temperature and bladder control | Hyperflexion injuries

Question 92

Mallet finger

Answer 92

Disruption of the extensor tendon at level of DIP Hyperflexion of DIP Tx: splint, refer for surgical repair

Question 93

Jersey finger

Answer 93

Disruption of FDP at level of DIP | Extension at DIP (like grabbing a jersey)

Question 94

Gamekeeper's thumb

Answer 94

Avulsion of ulnar collateral ligament (UCL) at thumb-MCP joint Forced abduction and extension Tx: thumb spica, refer for surgical repair

Question 95

Erythema multiform

Answer 95

Target lesions Most common cause = HSV Common bacterial cause = Mycoplasma penumoniae

Question 96

Schistosomiasis

Answer 96

Flu-like illness: fever, cough, HAs myalgias *eosinophilia Late complications: cirrhosis, renal failure, pulmonary complications Tx: Praziquantel

Question 97

Wallenberg syndrome

Answer 97

Lateral medullary infarct Sx: disequilibrium, vertigo Ipsilateral Horner syndrome (anhydrosis, mitosis, ptosis) Ipsilateral limb ataxia Loss of pain/temperature contralateral limb Hearing intact vs acoustic neuroma (hearing loss) Causes: vertebral artery dissection or atherosclerosis

Question 98

Cyanide poisoning mechanism

Answer 98

Inhibition of oxidative phosphorylation causes lactic acidosis Tx: sodium nitrite, sodium thiosulfate, hydroxycobalamin Avoid nitrites in concomitant CO poisoning

Question 99

CN III palsy clinical findings

Answer 99

Down and out | If pupillary sparing --> CVA

Question 100

Ciguatera vs scromboid

Answer 100

Ciguatera: GI symptoms (N/V/D, crampy abdominal pain) and neuro symptoms (perineal paresthesia, cold allodynia, numbness) --> tx = supportive Scromboid: histamine-like toxin --> flushing --> tx = anti=histamines

Question 101

Prinzmetal angina

Answer 101

Vasospasm | Can be relieved with exercise

Question 102

Tranexamic acid

Answer 102

Use in hemorrhagic shock due to trauma Best to give within 3 hours Decrease in mortality without increase in thrombotic events

Question 103

Middle cerebral artery stroke

Answer 103

contralateral arm/face > leg weakness, ipsilateral homonymous hemianopsia, dysarthria, aphasia

Question 104

CN III -oculomotor

Answer 104

``` Levator palpebrae Superior and inferior rectus Medial rectus Inferior oblique Pupillary constrictor Palsy --> ptosis, "down and out" Pupil sparing = infarct Mydriasis = mass, aneurysm ```

Question 105

Myxedema coma

Answer 105

Hypothermia Non-pitting periorbital edema "hung-up reflexes" - delayed relaxation phase Parethesias Median nerve palsy Hyponatremia, hypoglycemia, hypoventilation

Question 106

Goodpasture syndrome

Answer 106

Glomerulonephritis and diffuse alveolar hemorrhage

Question 107

Digoxin toxicity rhythm disturbances

Answer 107

PVCs = most common pathognomonic = bidirectional tachycardia and atrial tachycardia with AV block Tx: digibind

Question 108

Missed abortion

Answer 108

``` Intrauterine demise with retained products Vs incomplete (some tissue expelled) ```

Question 109

Magnesium toxicity

Answer 109

Decreased DTRs, decreased respiration, decreased CNS

Question 110

Reactive arthritis (Reiter syndrome)

Answer 110

Arthritis, urethritis, uveitis/conjunctivitis Common after chlamydia or shigella, campylobacter or yersinia infection (GI or GU infections) Seronegative spondyloarthropathies - ankylosing spondylitis, psoriatic arthritis, reactive arthritis and arthropathy of IBS --> commonly affect SI joint, *RA negative, *HLA-B27 positive

Question 111

How long does it take for a G-tube to mature?

Answer 111

2-3 weeks

Question 112

Septic arthritis pathogens

Answer 112

Staph aureus, Gp A strep, strep pneumo, neisseria gonorrheae (young adults) Body fluid analysis -- low viscosity, low glucose, WBC > 30K

Question 113

Bacterial tracheitis (aka laryngotracheobronchitis or pseudomembranous croup or bacterial croup)

Answer 113

5-8 years old Staph aureus, strep pneumo, strep progenies, H flu, mortadella catarrhalis Abx and consult ENT

Question 114

Mechanism of diabetes medications

Answer 114

Sulfonlyreas - stimulate pancreas to release insulin --> hypoglycemia Insulin -stimulates tissue uptake of glucose, suppresses hepatic gluconeogenesis, suppresses peripheral lipolysis Metformin - cause lactic acidosis

Question 115

Jarisch-Herxheimer reaction

Answer 115

Treating syphillis with PCN --> endotoxin release --> fever, rigors, hypotension, tachycardia

Question 116

Neurosyphillis

Answer 116

Meningitis, dementia, neuropathy Argyll-Robertson pupils (accommodate but don't react) Tabes dorsalis (decreased sensation and DTRs lower extremities -- affect dorsal column) Tx: PCN