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HY review #4 Part 2 Flashcards

1
Q

What is the biggest risk factor for the following disorders?
Bladder cancer:
Lung cancer:
Pancreatic cancer:
Prostate cancer:

*Of all the Above, which causes blastic bone lesions?

*Which cancer (listed above or not) can cause both blastic and lytic lesions?

A

Bladder cancer: → smoking
Lung cancer: → smoking
Pancreatic cancer: → smoking
Prostate cancer: → Age

Blastic bone lesions → Prostate cancer

Both blastic and lytic lesions → Breast cancer

Bladder, Lung, Pancreatic cancer → lytic lesions (chew up bone)

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2
Q

-What is the biggest risk factor for Renal cancer?
-What paraneoplastic syndrome is assoc w/ renal cancer ?
-Initial imaging test?
-Next step after imaging?

A

Smoking
[Paraneoplastic: ↑ EPO = ↑ Hct aka 2º Polycythemia]
Initial dx test → CT A/P with contrast
Next step in management → Nephrectomy
──
FYI: Can’t biopsy bc if you rupture it you’ll spread cancer all over.
Same goes for ROTA cancers
(RCC, Ovarian, Testicular, Adrenal)

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3
Q

HY HY HY
43F + BMI is 48.
Has tried 2 hrs of daily exercise and eats a low carb/fat diet.
What is the next best step in the management of this patient?

A

Gastric Bypass
(HY HY HY)

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4
Q

2 main indications for Gastric Bypass:

Does this surgery reduce mortality?

A

BMI> 40
BMI>35 + Co-morbidities (HTN, DM, HF)

Reduce mortality → YES

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5
Q

24 hr history of abdominal pain, severe vomiting, &
no bowel movement 4 years after gastric bypass
Dx/Tx?

A

SBO s/t Adhesions from abdominal surgeries (mcc of SBO)
Tx: NGT and suction

If Peritoneal signs are present = Laparotomy

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6
Q

Fevers and worsening epigastric pain with peritoneal signs 3 days after gastric bypass
dx/tx?

A

Anastomotic leak
Ex-Lap

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7
Q

1 month after Gastric Bypass, the patient returns for follow-up.
She complains of episodes of diarrhea, nausea, and dizziness that occur 2 hrs after she eats a meal.
Dx:
Dx testing:
Tx strategies:
Type of diarrhea:

A

Dumping Syndrome
Gastric Emptying Study (gastric scintigraphy)
Small frequent meal and low-carb diet (less osmotically active)

osmotic diarrhea
──
Rapid gastric emptying → pyloric sphincter is bypassed after surgery → once food enters stomach it goes immediately to the small intestine → this attracts water into intestine →osmotic diarrhea (resolves itself)

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8
Q

Mild bone pain, mild QT prolongation on EKG after gastric bypass surgery, tapping the cheek produces facial muscle spasms.
Dx:
Pathophysiology:
Expected PTH levels:
Tx strategies:

A

Hypocalcemia
s/t Decreased duodenal reabsorption
↑ PTH
Tx: Calcium + VitD supplementation

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9
Q

Shortness of breath and generalized fatigue in a menstruating female 1 year after gastric bypass surgery who was lost to follow up.
Dx:
Pathophysiology:
Tx strategies:

A

Iron def anemia
Poor iron absorption in duodenum
Tx: Iron supp + Orange Juice

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10
Q

What should be supplemented in pts who’ve had a gastric Bypass when they present with SBO symptoms to reduce the risk of neurologic sequelae?

A

Give Thiamine [vit B1]
(bc high risk for Wernickes)

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11
Q

(+) Babinski & Romberg tests (Dorsal column disfunction)
2 years after Gastric Bypass surgery in an individual lost to follow up?
Dx?

A

Vitamin B12 def
(UMN + Dorsal Column sxs = Subacute combined degeneration of the spinal cord s/t B12 deficiency)

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12
Q

Hemidiaphragm elevated after inserting a central line

A

Dmg to Phrenic Nerve (paralysis of diaphragm)

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13
Q

Feeling of ear fullness + vertigo + Tinnitus + episodic hearing loss
dx/tx(2)?

A

Menier’s dz (endolymphatic hydrops)
Tx: Diuretic or Gentamicin ablation of CN8 (when diuretics no work)

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14
Q

Management of rotator cuff injury
1st line/2nd line tx?

A

Shoulder strengthening exercises

2nd line: inject steroids

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15
Q

Teenager presents with rapid onset and offset neuro deficit or consciousness (resolves within seconds to an hour). Perioral rash noted on exam.

Dx?

A

inhalant abuse (Glue, Taulene)
neuro deficits → pass out → wake up and are okay

FYI: can cause Parkinson sxs

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16
Q

Histological correlate of ARDS

A

Diffuse alveolar damage

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17
Q

Enlarging breast mass in a 55 yo F on hormone replacement therapy. NBSIM?

A

c/f Breast cancer
get Mammogram
Then stop HRT

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18
Q

2 modes of emergency contraception.
Which is most effective?

A

Copper IUD (better)
Uripristol (Plan B)

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19
Q

Rising Cr and K after starting candesartan.
Diagnosis?

A

Renal Artery Stenosis
───
(this is how it is tested)
Glomerulus is drained by efferent arteriole
In Renal a stenosis you bring in less blood via afferent a. to glomerulus → thus lowering Hydrostatic pressure.
→ Adding an ACE-I or ARB → dilates the efferent arterial → further reducing hydrostatic pressure in glomerular capillaries → resulting in ↓ GFR and ↑ Cr

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20
Q

Neurologic sxs present in a pt with a hx of small bowel resection
Diagnosis (cause of sxs)?

A

Vitamin B12 deficiency
(especially if Crohn’s hx)

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21
Q

2 yo boy that screams and cries profusely when he begins kindergarten.

A

Separation anxiety
Provide reassurance

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22
Q

Predominant mode of physician compensation in the US

A

Fee for Service

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23
Q

Method of CMS (center for medicare services) physician reimbursement that emphasizes quality improvement

A

→ Value- Based Care

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24
Q

Classic drugs used in the management of HIT on NBMEs?

A

Direct Thrombin (2a) inhibitors (agatroban, dabigatran)
───
or rarely Factor 10 inhibitor (apixiban)

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25
40 yo obese F presents with **painful draining lesions** under the axilla that have not responded to 1st and 2nd line treatment. Dx/NBSIM/ List the 1st & 2nd line tx What Glands affected?
**Hidradenitis Supparativa** 1st Antibiotics (Topical Clindamycin or PO Tetracycline) 2nd Steroid injection NBSIM IS 3rd line tx, **Surgery** **apocrine sweat** glands are inflamed
26
Most susceptible region of colon to infarction from vessel thrombosis/systemic hypoperfusion
Left Colic Flexure (Splenic flexure) watershed area of supply
27
Right heart failure s/t Pulmonary HTN, COPD, CF, OSA etc.
Cor Pulmonale (RHF s/t pulmonary cause)
28
Management of seborrheic dermatitis
Selenium sulfide shampoo
29
Most common location of a **carcinoid** mass? Spreads to ____ becoming symptomatic.
**Appendix** Spreads to **Liver** causing sxs: Flushing Wheezing Diarrhea RH **valve** issues **high levels of 5-HIAA**
30
Most important nutritional intervention in the treatment of hemorrhoids
add FIBER
31
E’lyte abnormalities found in a patient vomiting.
Hypocholermic, hypokalemia metabolic alkalosis (volume depletion causes high aldosterone)
32
Risk of a boy becoming a hemophiliac if his mom is a carrier and his dad is not.
50%
33
Perioral cyanosis 3 hrs after receiving bupivacaine in an axillary nerve block dx/tx?
**Methemoglobinemia** Tx: **Methylene Blue** SaO2 low + PaO2 nl ─── CN poisoning = SaO2 nl + PaO2 nl CO poisoning = SaO2 low + PaO2 nl
34
What should be done on NBMEs in a HIV negative individual who is a partner of a HIV+ individual?
**Pre**-Exposure ppx Emtriatabine + Tenofovir ± Raltegravir
35
Treatment of herpetic whitlow?
**PO** Acyclovir
36
Diagnostic test for BP-Positional Vertigo. & Treatment maneuvers
Dxt: Dix-Hall Pike test Tx: Epley or Semont Manuever
37
In a patient with a stroke, what is the Blood Pressure value you should aim to stay below of? What drug should be used in achieving this goal?
<220/120 (permissive HTN) **Labetalol** —- FYI: AHA guidelines say stroke pts not qualified for TpA or thrombectomy are allowed permissive HTN to < 22/120. Pts who are qualified should have BP lowered to <185/110 before treatment is initiated. In acute ischemic stroke pt with cardiac comorbidities may need emergent BP reduction no more than 15% of initial BP within 24 hrs)
38
Long time smoker with bilateral calf pain Dx/Dxt/tx(3)?
Peripheral Artery Disease 1st → do ABI * if **less than 0.7** = PAD confirmed * if ABI is ↑/wnl → Toe Brachial Index → Monkeberg Calcific sclerosis Tx strategies: 1st line: Supervised **walking/ exercise** program 2nd line: Cilastozole (antiplatelet + vasodilator) 3rd line→ get **CT Angio** of extremity for **Surgical** planning
39
If pt with suspected PAD has an Elevated or Normal ABI NBSIM/Dx? (Normal ABI: 0.9 – 1.4)
Toe Brachial Index Monkeberg Calcific sclerosis
40
Pt presents with calf pain on exertion + Buttock pain + Erectile Dysfunction. Dx?
Aorto-iliac disease (aka Leriche syndrome)
41
Pt diagnosed with PAD and started on supervised exercise program. NBSIM?
start a STATIN to prevent CVD events ── (technically, they also need an Aspirin, but NBME doesn't care)
42
Treatment for pancreatitis s/t hyperTG
Fibrates
43
Sudden onset severe chest pain **Widened mediastinum** Left Pleural effusion ± Hoarse voice Dx/ NBSIM (if pt is stable vs unstable)
Aortic Dissection unstable: TEE stable: CT Angio chest ─── R. Laryngeal n. dmg → vocal cord paralysis, respiratory failure, hoarse voice
44
Management of Aortic Dissection Type A → ascending aorta ± descending aorta involved Type B → only descending involved
A → Surgery + Beta blocker B → Beta blocker + Observation (labetalol, sotalol, metoprolol)
45
Aortic Dissection BRFs (~4)
HTN Marfans Ehler’s danlos 3º Syphilis (Aortitis)
46
Infertility in a Cystic Fibrosis male vs Cystic Fibrosis female is due to what?
Male → Agenesis of Vas Defrens Female → Thick Cervical Mucus
47
Female with Benign adnexal mass, ascites & pleural effusion (TRIAD) Sxs resolve after resection of mass Dx?
Meig’s Syndrome
48
5F child + foul smelling vaginal discharge ↑ Wbcs Dx?
Vaginal Foreign Body (kids do the grossest things)
49
Loss of **peripheral** vision first then central vision dx?
**Glaucoma** Risk factors include → Steroid use + Diabetes
50
Loss of **central** vision first then peripheral vision dx?
Macular Degeneration
51
Presents with headache, eye pain, nausea, and decreased visual acuity. Exam → Red eye + **Rock Hard , Firm Eyeball** + fixed, mid-dilated pupil dx/tx(2)?
Angle Closure Glaucoma Muscarinic **Ago**nist (**Pilocarpine**) + **Laser Iridotomy**
52
Contraindicated exam in pt's with Acute Angle- Closure Glaucoma?
Dilated Eye Exams ─── pupillary dilation from anticholinergic medications (Tolterodine), sympathomimetics, or low ambient light.
53
Open Angle Glaucoma (Chronic) Treatment options (4)
* Prostoglandin analogs (Latanoprost, Bimatoprost) * Alpha 2 agonist (Aproclonidine, Brimonidine) * Beta Blocker (Timolol) * CAH inhibitor (Acetazolamide, Dorzolamide) ─── Prostaglandin analogs dilate canal of schlemm to incr drainage → it also increases eye-lash growth :)
54
33 F presents with a 12 hour history of severe groin pain. Recently received Cefazolin for an infection. Urine pH 7.1 (**basic**) CT pelvis → Large stone in renal pelvis Dx/Bug/NBSIM?
Staghorn Calculi Proteus Mirabilis (Ureas bugs → makes urine basic) Surgical Removal of stone ~normal urine pH: 5– 7 (approaching these values is concerning)
55
Aside from not moving position for long periods of time what else is a big risk factor for the development of Pressure (Decubitus) ulcers and their impaired healing? NBSIM if muscle or bone are visible in the ulcer?
**Poor protein/nutrition** Caloric Nutritional Support is necessary for wound healing **Debride Ulcer** ————- FYI: poor nutrition impairs wound healing after surgeries too
56
23 yo Norwegian immigrant presents with a 6 hr history of severe RUQ **pain** & N/V. Physical exam: tachycardia & **scleral icterus** ↓ Hct is 24% ↑ Total bilirubin 8 (Indirect>direct) Multiple family members have required blood transfusions Patient is up to date on the pneumococcal, meningococcal, and H.Flu vaccine series. Dx/Tx?
**Hereditary Spherocytosis** (AD) Splenectomy (Autosomal Dominant congenital hemolytic disorder → RBC are vulnerable to osmotic stress) **Negative** Coombs test in HS *eliminates* autoimmune Hemolytic Anemia note: TTP is also coombs Negative however HS has ↑MHHC unlike TTP
57
Hereditary Spherocytosis (AD) results from a mutation in __ & ___ proteins resulting in excessive hemolysis of RBCs by splenic macrophages (MQs).
SPECTRIN ANKRIN (band proteins)
58
Finding can be seen in Cushing dz and Addison's dz
Hyperpigmentation
59
Cushing Syndrome: Adrenal cortex adenoma Buffalo Hump & Moon Faces __ Cortisol & __ ACTH Addison: Adrenal insufficiency Hyperpigmentation, Fatigue, GI sxs Hyperkalemia/Hyponatremia (low Aldo) ↓ Bicarb __ Cortisol & __ ACTH + one unique lab value in Addison's that may be given?
Cushing: ↑ Cortisol & ↓ ACTH Addison: ↓ Cortisol & ↑ ACTH + ↑ **Eosinophils**
60
Diagnostic test for pt w/ suspected Addison's dz? Treatment for Addison’s (2)?
**Cosynotropin** (synthetic ACTH analog) **test** If Cortisol **does not** rise = confirms Addison’s dz Tx: **Hydrocortisone** (Replaces cortisol) & **Fludricortisone** (replaces Aldosterone)
61
Diagnostic Steps for suspected Cushing's dz 1st: Confirm they have adrenal excess (3) 2nd: Get serum ACTH levels to see if - ↓ ACTH Independent → NBSIM - ↑ ACTH Dependent → NBSIM
**1st pick one test** -Dexamethasone suppression (cortisol will not suppress) -24hr urine cortisol -Late night salivary cortisol —————— **2nd is it ACTH Independent or Dependent** ↓ ACTH (**independent**) = **adrenal adenoma** making cortisol → **CT or MRI Abdomen/Adrenals** ↑ ACTH (**dependent**) = pituitary or lung tumor secreting too much ACTH → **High Dose** Dexamethasone suppression test ——— **Results of high dose Dex test** ↓ Cortisol → **Pituitary adenoma** making ACTH (**Cushing’s dz**) → **MRI Brain** ↑ Cortisol → **Paraneoplastic** disorder (**Small Cell Lung Cancer**) → **Chest CT**
62
**Acute cholangitis** Pentad: ____ + ____ + ____ + RUQ pain + Jaundice Labs/Imaging findings : ↑ **Direct** Bilirubin ↑ LFTs ± Anion gap metabolic acidosis s/t LDH in sepsis. **Dilated CBD** **Tx** ?
Fever + Hypotension + AMS Tx: **ERCP**
63
Abdominal Pain + N/V Abdominal x-ray shows dilated loops of small bowel and **air in the intrahepatic bile ducts** Dx/Tx?
gallstone ileus (s/t biliary-enteric fistula) Enterolithotomy a form of mechanical small bowel obstruction causing pneumobilia (air in the biliary tree)
64
infection of the gallbladder wall with gas-forming bacteria & Air **within** the gallbladder wall Requires emergency cholecystectomy Dx? Risk factors (2)
emphysematous cholecystitis BRF: DM, Atherosclerosis (Clostridium, E. coli )
65
Teenager with episodic jaundice provoked by physiologic stress like illness or hunger. **No RUQ pain** ↑ Unconjugated (**Indirect**) bilirubin Normal LFTs/CBC Dx?
Gilbert syndrome No treatment required ↓ UDP glucuronosyltransferase activity = ↓ conjugation of bilirubin
66
Pregnant patient Acute Jaundice **Hypoglycemia** Fulminant liver failure & DIC dx?
Acute fatty liver of pregnancy
67
pRBC transfusions are recommended in **acute** GI bleeds for patients with hemoglobin <__ g/dL.
Hgb < 7
68
Elderly pt + anemia + FOBT (+) NBSIM?
Colonoscopy
69
chronic (>2w) diarrhea + Anemia + ↑ESR/CRP Dx/NBSIM?
**Inflammatory bowel disease (IBD)** (Crohn disease, Ulcerative colitis) **Colonoscopy**
70
Elderly Pt + worsening **LLQ** pain + **peritoneal signs** (rebound, rigidity, guarding) **Free air** under diaphragm (KUB) Dx?
Diverticular Perforation
71
Elderly + chronic constipation + anemia + intermittent painless blood in stool/hematochezia dx/NBSIM?
Diverticulosis (causing Diverticular Bleeds) Colonoscopy mcc of lower GI bleeds in adults
72
Elderly pt + **fever** + **LLQ** abdominal pain + recent **change in bowel habits** Labs ↑ Wbcs ± ↓ Hb ↑ BUN + Cr ↑ ESR/CRP (+) FOBT ± tender, palpable mass ± Pyuria Dx/NBSIM/Contraindicated test?
Diverticulitis CT abdomen with IV contrast **colonoscopy is contraindicated** *colonoscopy recommended 6–8 weeks after the resolution to r/o malignancy*
73
Typically asymptomatic but occasionally presents in **elderly** pt as **changes in bowel habits** + **abdominal discomfort** (usually LLQ sigmoid)
Diverticulosis can result in **diverticular bleed** + anemia + Hematochezia ± abdominal pain
74
hepatocellular pattern of liver injury (elevated AST/ALT, normal ALP). List 7 causes for this pattern of liver injury
Viral Hepatitis Alcoholic Hepatitis nonalcoholic fatty liver disease (NAFLD) Autoimmune Hepatitis drug-induced liver injury Ischemic hepatic Injury Wilson dz Hemochromatosis
75
Intermittent scleral icterus + ↑ Direct Bilirubin + normal LFTs dark granular pigments in hepatocytes dx?
Dubin-Johnson syndrome Impaired hepatic excretion of conjugated bilirubin
76
Diabetes + Arthralgias + hyperpigmentation ↑LFTs dx/tx?
Hemochromatosis (hepatic iron overload) tx: Phlebotomy Can be seen in Post-Menopausal women b/c no monthly bleeding (biological phlebotomy lol)
77
anti- ADAMTS-13 antibodies are present Thus there is not enough ADAMTS-13 around to combine w/ vWF Matalloprotease in order to inactivate vWF resulting in _______ . Dx/finish describing the rest of the dz pathology
TTP vWF is always active → ↓PLTs (auto-immune dz)
78
Fever + Neuro sxs +Hemolytic Anemia + Shistocytes (due to MAHA) ↓ PLTs ↑ Cr dx/tx(2)?
TTP 1. Plasmapheresis 2. IvIg
79
1. How does TMP-SMX cause Hyperkalemia? 2. How does it impede the degradation of Warfarin
1. Sodium Channel blocker 2. CYP2C9 inhibitor (which breaks down Warfarin) -↑ Warfarin -↑ INR (supratherapeutic)
80
List one cause of Secretory Diarrhea HY on NBME
Cholera Toxin (Adenylate Cyclase)
81
List one cause of Osmotic Diarrhea HY on NBME
Lactose Intolerence Dumping syndrome
82
Enteric cancer associated with Celiac Dz (gluten-intolerence)
T-cell Lymphoma

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