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free120 Flashcards

1
Q

Young woman presenting with adult-onset asthma, hemoptysis, fever and sensory abnormalities of the upper and lower extremity most concerning for
next step?

A

Eosinophilic granulomatosis with polyangiitis (Churgg-Strauss)
PAN – Palpable purpura, Asthma/sinusitis, Neurological symptoms (wrist drop, sensory)
Serum antineutrophil cytoplasmic autoantibody assay (p-ANCA)
MPO-ANCA
will see eosinophilia

adult onset asthma with eoosinophilia: churg strauss or allergic bronchopulmonary asperfillosis

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2
Q

Elderly woman with many vaginal deliveries presenting with inability to void that resolves with catheterization and with physical exam most consistent with pelvic organ prolapse

A

urinary retention

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3
Q

If a patient recently began treatment with methimazole/propylthiouracil and presents with fever and a sore throat, the next best step

A

get a CBC

agranulocytosis

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4
Q

routine prenatal testing:

A

Routine testing at initial visit: HIV, Urine protein/culture, Chlamydia PCR, Rh(D) antibody screen, Hemoglobin/Hematocrit, Hepatitis B serum antigen, Rubella and varicella titers, Pap test (if indicated)

24-28 weeks: Rh(D) antibody screen, gestational diabetes screen, hemoglobin/hematocrit

35-37 weeks: Group B Strep culture

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5
Q

Periodic sharp wave complexes on EEG
(2) Increased 14-3-3 CSF assay
(3) MRI findings on caudate nucleus and/or putamen

A

Creutzfeldt jakob
rapid progressive
startle reflex

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6
Q

increased CSF beta amyloid

A

alzheimers (amyloid)

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7
Q

increased methylmalonic acid

A

vitamine b-12 megaloblastic anemia + neuro sxms

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8
Q

hypercalcemia, bone pain, anemia, kindey problems

A

multiple myeloma
serum protein electropheresis

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9
Q

Young woman with lupus presenting with bleeding gums and petechiae/ecchymosis of extremities found to have mild anemia and pronounced thrombocytopenia most consistent with
next step?

A

Immune thrombocytopenia
TIP
1ST LINE: STEROIDS, ivIG

Patients with lupus tend to have pancytopenia, most commonly due to autoantibodies leading to immune-mediated destruction (particularly of platelets and leukocytes; multiple potential ways lupus can lead to anemia)

Immune thrombocytopenia classically leads to increased number of megakaryocytes on bone marrow biopsy and few platelets on peripheral smear

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10
Q

Adolescent boy with recent viral illness presenting with fatigue and respiratory distress found on physical exam to have hypotension, lung crackles, and a new cardiac murmur most consistent with

A

myocarditis

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11
Q

Adolescent boy with acute, unilateral testicular pain with physical exam demonstrating elevated right testicle with absent cremasteric reflex on the right with a negative Prehn’s sign (pain unrelieved with elevation) most consistent with

A

testicular torsion
genitofemoral nerve (travels within spermatic cord is affectred by torsion)
GO STRAIGHT TO OR
NEED PERFORM OCHIOPEXY ON BOTH TESTICLES

vs

testicular pain relieved with elevation –> Positive Prehn’s sign –> Epididymitis

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12
Q

potential symptoms of sarcoidosis:

A

lupus pernio (subacute raised violacious facial lesions)
bell’s palsy
uvietis
erythema nodosum( also seen in IBD, TB, Behcets, fungal infections)

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13
Q

Polymyositis/Dermatomyositis:

Polymyalgia rheumatica: Stiffness, associated with temporal arteritis

A

Inflammed with increased ESR and increased CK

increased ESR and normal CK

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14
Q

Indications for electroconvulsive therapy in setting of depression:

A

(1) Refractory to standard treatment (2) Presence of psychotic features (3) Psychiatric emergency (pregnancy patient, refusal to eat/drink, imminent risk of suicide)

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15
Q

antidepressant for people who are not eating enough and who have trouble sleeping

A

mirtazapine

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16
Q

A young girl who was started on a penicillin for strep pharyngitis 8 days ago presenting with fever, lymphadenopathy, urticaria, arthralgias and proteinuria most consistent with

A

SERUM SICKNESS type III hs
is mediated by deposition of antigen-antibody complexes –> to prevent future episodes we want to avoid giving patient “antigen” and therefore we should avoid penicillins

Serum sickness often triggered by certain drugs (antibiotics) or infections (hepatitis B)

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17
Q

Young woman with poorly controlled type 2 diabetes currently admitted for pyelonephritis that is refractory to standard treatment (fluoroquinolone) with persistent fevers and costovertebral tenderness, concerning for

A

complicated pyelonephritis so workup
CT SCAN OF ABDOMEN

Persistent symptoms despite 48-72 hours of therapy (2) History of nephrolithiasis (3) Unusual urinary findings (gross hematuria) (4) Concern for complicated pyelonephritis (renal abscess, emphysematous pyelonephritis, septic shock)

Likely would want to wait on blood cultures before deciding to broaden coverage because quinolones should cover almost all causative pathogens in setting of pyelonephritis

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18
Q

Young man with significant immunodeficiency admitted to ICU with septic shock and hypotension refractory to 4L of fluid showing early signs of volume overload (inspiratory crackles, non-collapsible IVC) start on:

A

SEPTIC shock: hypotension with fever
give Norepinephrine

vs

hydrocortosone in pt with adrenal insufficiency with just refractory hypotension

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19
Q

Middle-aged woman with type 2 diabetes and hypertension recently started on lisinopril who presents with signs of volume overload (lower extremity edema, lung crackles, S3 gallop), worsening hypertension and a severely increased creatinine (1.2 –> 4.0)

A

acute kidney injury
especially if pt had bilateral renal artery sclerosis of fibromuscular dypslasia would worsen with ace-i causing aki (pre-renal –> ATN)

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20
Q

wrist widening, frontal bossing, leg bowing, hypertrophy of costochondral joints (“rachitic rosary”)

A

Osteomalacia/Rickets –> Poorly mineralized bone often in setting of vitamin D deficiency or problems activating vitamin D (liver/renal disease)

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21
Q

hearing loss, multiple fractures, and hyperflexible joints presenting with potential lower extremity fracture in setting of minor trauma,

A

AD - ↓ production of type I collagen
osteogenesis imperfecta: (1) Frequent fractures (2) Blue sclerae (due to ability to see underlying choroidal veins) (3) Conductive hearing loss (4) Short- normal stature (5) Dentinogenesis imperfecta (thin, greyish teeth) (6) Joint hypermobility

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22
Q

Middle-aged man with ST-elevation MI complicated by extensive anterolateral akinesis who on day 5 of hospitalization develops bilateral lower extremity pain/paresthesias, cyanosis, hypotension, and weak upper extremity pulses with absent lower extremity pulses

A

aortic embolism

Occlusion at aortic bifurcation: bilateral acute limb ischemia (most common presentation)
Limb pain
Pallor or cyanosis
Absent pulse
Paresthesia and paralysis
Diagnostics
CT angiography (confirmatory test)
Treatment
embolectomy
Aortobifemoral bypass

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23
Q

An elderly man with a significant smoking history presents with chronic shortness of breath and cough with physical exam consistent with hypoxemia, fine/dry crackles of both lungs and clubbing with chest x-ray showing scattered reticular opacities most consistent with

A

idiopathic pulmonary fibrosis
High-resolution CT scan of the chest

crackles: either pulmonary edema (HF exacerbations) or interstitial lung disease (IPF, Sarcoidosis)

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24
Q

Serum antiglomerular basement membrane antibody assay

A

Goodpasture syndrome –> Young man with hemoptysis and hematuria

25
Q

Four main types of lacunar infarct (highly associated with poorly controlled hypertension):

A

(1) Pure motor stroke (2) Pure sensory stroke (3) Ataxia-hemiplegia syndrome (4) Dysarthria-clumsy hand syndrome

26
Q

Young primigravid woman at 21 weeks’ gestation who presents with acute shortness of breath, GI symptoms, headache, muscle aches, fever and chest x-ray with unilateral interstitial infiltrates most concerning for

A

influenza A virus (the flu)
Muscle aches and GI symptoms very common in patients with influenza infection and often can help differentiate it from a rhinovirus infection or a bacterial pneumonia

27
Q

Young woman with chronic earplug use who presents with subacute unilateral ear itchiness with physical exam notable for ear pain with manipulation of pinna and an erythematous/edematous ear canal most consistent with

A

otitis externa
ear pain with pulling pinna
vs
relief with pulling pinna – otitis media

otitis externa: acetic acid drops or floroquinolones

28
Q

Most cases of sinusitis are viral in origin, but you should be concerned for bacterial rhinosinusitis if at least 1 of the following 3 criteria are met

A

1) Persistent symptoms >10 days (2) Febrile illness for >3 days (3) Symptoms improve and then get worse
Bacterial rhinosinusitis –> Treat with amoxicillin + Clavulonic acid (Augmentin)

vs viral sinusitis is without fever and managed conservatively

29
Q

Adolescent boy with VACTERL presenting with subacute cough accompanied by
expiratory stridor, forced vital capacity > slow vital capacity and a scooped-out flow-volume loop, all of which are associated with

A

tracheal collapse
Scooped out flow-volume loop = Obstructive lung disease (problem getting air OUT of the lungs)
VATER syndrome = VACTERL = Constellation of mesodermal anomalies leading to Vertebral defects, Anal defects, Cardiac defects, Tracheal or Esophageal anomalies (often fistula), Renal defects and Limb defects

30
Q

Indications for Fine-Needle biopsy:

A

thyroid nodule larger than 2cm
or 1cm + u/s showed microcalcifications, irregular markings

REGARDLESS ALWAYS DO U/S AND TSH/T3/T4 FIRST

31
Q

Baby born to mother with well-controlled HIV (viral load < 1000 copies/mL)
VS
poorly controlled

A

zidovudine only

vs

multidrug antitretroviral therapy

32
Q

Macroprolactinoma (>1 cm) or symptomatic microprolactinoma:
vs
larger than 3cm or continues to grow with dopamine agonist

A

cabergoline, bromocriptine

transphenoidal surgery

33
Q

pseudoseizure (no post-ictal state, no tongue biting, no incontinence, occured after a negative emotional state0
next step?

A

VIDEO EEG monitoring

34
Q

Overweight patient with increased LH:FSH ratio (often >3:1)

A

PCOS

35
Q

post-menopause labs

A

increased FSH

premature menopause: primary ovarian failure –> hx of radiation or smoking

36
Q

Young woman who was recently hospitalized for crushing chest pain resolving with nitroglycerin with ST-depressions on ECG and a clean cardiac catheterization who continues to have short unprovoked episodes of chest pain most consistent with

A

Prinzmetal’s angina should be treated with calcium channel blockers or nitrates

37
Q

MEN 1 –> 3 P’s –> Pituitary tumors, Parathyroid adenoma, Pancreatic tumor (Zollinger-Ellison, VIPomas, etc.)

vs

MEN 2A –> 2 P’s and 1 M –> Parathyroid adenoma, Pheochromocytoma, Medullary thyroid cancer
MEN 2B –> 1 P and 2 M’s –> Pheochromocytoma, Medullary thyroid cancer, Mucosal neuromas

A
38
Q

Nitroblue tetrazolium testing

A

Chronic granulomatous disease –> Increased risk of Catalase positive organisms, often presents with recurrent Staph skin infections

39
Q

Young woman with complicated pregnancy (polyhydramnios, gestational diabetes) who has artificial rupture of membranes followed by a prolonged deceleration (on order of minutes), concerning for

A

umbilical cord prolapse
if pt has membrane rupture and then shortly after abnormal fetal heart tracings
usually will see fetal bradycardia, variable deceleraitons and prolonged decelerations > 1min

Risk factors for umbilical cord prolapse: Breech presentation, artificial rupture of membranes, polyhydramnios

Management of umbilical cord prolapse: Elevate the fetal head and perform a C- section (NOT appropriate to replace the cord or to allow the patient to continue to labor)

40
Q

Young woman with complicated pregnancy (polyhydramnios, gestational diabetes) who has artificial rupture of membranes followed by a prolonged deceleration (on order of minutes), concerning for

A

umbilical cord prolapse
if pt has membrane rupture and then shortly after abnormal fetal heart tracings
usually will see fetal bradycardia, variable deceleraitons and prolonged decelerations > 1min

Risk factors for umbilical cord prolapse: Breech presentation, artificial rupture of membranes, polyhydramnios

Management of umbilical cord prolapse: Elevate the fetal head and perform a C- section (NOT appropriate to replace the cord or to allow the patient to continue to labor)

41
Q

early
variable
late
decelations

A

Early deceleration –> Deceleration mirrors contraction –> Sign of fetal head compression –> Benign finding

Variable deceleration –> Unassociated with contractions, steep/abrupt deceleration and recovery –> Sign of **umbilical cord compression **–> Most concerning if recurrent and with loss of variability

Late deceleration –> Deceleration occurs following contraction (nadir does not mirror peak of contraction) –> Uteroplacental insufficiency –> Most concerning if recurrent and with loss of variability; often most ominous of the deceleration patterns

42
Q

IBD (crohsn and ulcerative colitis) other findings:

A

skin disease (pyoderma gangrnosum, erythema nodosum), joint disease (inflammatory arthritis), eye disease (uveitis) and oral ulcers

43
Q

crohns disease kidney stones:

A

Crohn’s disease is specifically associated with calcium oxalate kidney stones (terminal ileal disease –> Impaired fat absorption –> Intra-intestinal calcium binds to fat instead of oxalate –> More free oxalate absorbed from the gut

44
Q

post op patient with super high glucose levels d/t

A

Decreased uptake of glucose by insulin-sensitive tissues

insulin resistance 2/2 to injury/stress

45
Q

Middle-aged woman with type 2 diabetes presenting with fever and a lower extremity lesion that is exquisitly tender, lacks sharp margins and has bullae with purplish discharge most consistent

A

with necrotizing fasciitis over cellulitis

2) 1) Pain out of proportion to examine (extreme pain > tenderness) (2) Rapid progression of symptoms (3) Severe systematic features (fever, chills, hypotension) (4) Crepitus or free air (5) Bullae (6) Purulent, cloudy discharge (7) Violaceous appearance of lesion (8) Paresthesia/Anesthesia at edge of lesion

go directly to OR

diabetic pts predisposed to necfas of perineal – fournier gangrene

46
Q

pt working at a plant where inhaling chlorine gas
what to do?

A

primary disease prevention: prevent it before it even occurs with vaccination, wearing a respirator
second disease prevention: screening for disease and manage asymptomatic disease (monthly pulmonary function tests)
tertiary disease prevention: treatment of disease (corticosteroid therapy)

47
Q

Middle-aged man without significant alcohol history presenting with abdominal pain radiating to the back and elevated amylase found to have a triglyceride level in the 1000’s, most consistent with pancreatitis due to hypertriglyceridemia
tx?

A

statins are the best lipid-lowering agent, with one key exception being the setting of hypertriglyceridemia-associated pancreatitis which should be treated with a fibrate because they lead to the most profound drop in triglyceride levels

48
Q

Middle-aged man with smoking history and likely COPD given baseline history presents in respiratory distress with significant hypoxemia despite mechanical ventilation with x-ray findings of diffuse bilateral alveolar infiltrates most concerning for

A

ARDS

high PEEP with low TV
ADD/increase PEEP

49
Q

nose bleeds, telangiectasias and, most concerning, AV fistulas (high-output heart failure)

A

Hereditary hemorrhagic telangiectasia

50
Q

Middle-aged woman with a 2-month history of fatigue and abdominal pain found to have anemia and a moderately differentiated adenocarcinoma in the ascending colon most consistent with right-sided colon cancer
next step?

A

Righ hemicolectomy (dont just take out the lesion but surgically remove half of it)

51
Q

SBP cirrhosis PMH>250
TX?

A

3rd gen cephalosporin cefotax ceftri

some cirrhosis pt can recieve flouroquinolones for prophylaxis
also should get a EGD for esopahgeal varices ppx

low temperature fever means that they are not fighting infection hard enough, aka low immune sxm, aka THIS IS BAD

52
Q

antiepileptics (phenobarbital and carbamazepine) + weak bones

A

induce p450 and increase metabolism of vitamin D
(osteomalacia/rickets/ vit d deficiency)

carbamazepine also causes folate deficiency

53
Q

primary amenorrhea:

A

girls who have not had secondary sexual changes (breast development mounds form, thelarche some pubic hair pubarche) by 13 or who have not had menarche by 15

54
Q

pleural fluid:

A

Light’s criteria (If at least 1 of the following conditions are true, then the effusion is exudative): (1) Pleural fluid protein: Serum protein ratio > 0.5 /// (2) Pleural fluid LDH: Serum LDH ratio > 0.6 /// (3) Pleural fluid LDH > 2/3 upper limit of normal serum LDH (often ~200)

EXudative effusions are due to increased vascular permeability often in the setting of inflammation (cancer increased protein or LDH in fluid, infection, autoimmune) and you can remember that they have fluid and EXtra substances (protein, cells, LDH, etc.)

Transudative effusions are often due to** increased hydrostatic pressure** (volume overload due to CHF exacerbation, CKD, etc.) or decreased oncotic pressure (nephrotic syndrome, malnutrition, etc.)

Empyema (walled off, purulent fluid collection secondary to infection) –> decreased glucose concentration (bacteria eat sugar), increased segmented neutrophil count

55
Q

First step in primary amenorrhea work-up:

A

Determine if uterus is present (physical exam, imaging) because if it is ABSENT then the patient either has
Mullerian agenesis (XX, normal breast and pubic/axillary hair development)
or Androgen Insensitivity Syndrome (XY, absent pubic/axillary hair with normal breast development)

56
Q

Second step in primary amenorrhea work-up:

A

primary amenorrhea AND has a uterus
FSH LEVELS:
low fsh –> pituitary/hypothalamus is dysfunctional (prolactinoma, hypothyroidism, functional hypothalamic amenorrhea)
normal fSH: FUNCTIONal defect: imperforated hymen

elevated fsh:ovaries are dysfunctional (turners, primary ovarian failure)

56
Q

Second step in primary amenorrhea work-up:

A

primary amenorrhea AND has a uterus
FSH LEVELS:
low fsh –> pituitary/hypothalamus is dysfunctional (prolactinoma, hypothyroidism, functional hypothalamic amenorrhea)
normal fSH: FUNCTIONal defect: imperforated hymen

elevated fsh:ovaries are dysfunctional (turners, primary ovarian failure)

57
Q

hereditary spherocytosis
coombs ( )

A

negative

vs

hemolytic anemia is +

NBME's (8 decks)

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