IM

Question 1

EPISODIC headache, palpitations, sweating (diaphoresis)

Answer 1

Pheochromocytoma

Question 2

In HIV/AIDS –> solitary esophageal ulcer, retinitis (floaters in eye), colitis

Answer 2

CMV

Question 3

Myeloproliferative disorder –> increased RBCs, WBCs, platelets

Predisposes to Budd-Chiari syndrome

Answer 3

Polycythemia vera

Question 4

Bicuspid aortic valve, coarctation of aorta

Short female, webbed neck (cystic hygromas), XO karyotype

Answer 4

Turner syndrome (heart defects)

Question 5

Endocrine disorder w/ high correlation w/ pernicious anemia (megaloblastic anemia)

Answer 5

Hashimoto’s thyroiditis

Question 6

Cold-agglutinin hemolytic anemia

“Squeaks” on ausc.

Answer 6

Mycoplasma/Chlamydia pneumonia

Question 7

Common in women shortly after childbirth from position of holding/lifting baby

Inflammation of abductor pollicus longus & extensor pollicus brevis

Answer 7

de Quervain’s tenosynovitis

Question 8

Inflammation and thrombosis in superficial veins (usually legs) that feel like palpable cords

Associated w/ pancreatic adenocarcinoma

Answer 8

Migratory thrombophlebitis (Trousseau syndrome)

Question 9

Microcytic anemia w/ normal RBC count & normal RDW

MCV very low; hematocrit slightly reduced

Answer 9

Thalassemia

Question 10

Refractory epigastric pain despite PPI treatment

Diarrhea & epigastric pain

Solitary ulcer in duodenum

Answer 10

Gastrinoma/ZE syndrome

Question 11

Onset of hypertension in females under 35 yo

Activates RAAS (hypokalemia)

Answer 11

Fibromuscular dysplasia

Question 12

Rhinorrhea, sneezing, allergic conjuctivitis

Classification:
    Intermittent (s/s  4 days/week or > 4 weeks)
    Mild
    Moderate-severe (1+ of following present):
        Impaired school work/performance
        Impaired daily/sport activities
        Sleep disturbance
        Troublesome s/s

Complications: sinusitis, asthma, nasal polyps

Answer 12

Allergic rhinosinusitis

Question 13

Causes of reversible agranulocytosis

Answer 13

Hyperthyroidism drugs –> propylthiouracil & methimazole

Question 14

Inflammatory disorder of small/medium blood vessels & nerves of extremities.

Look for:
MALE SMOKER
Normal proximal pulses; decreased-absent distal pulses
Ischemic ulcerations
Rest pain in distal extremities
Corkscrew pattern seen on angiogram (tortuous)

Answer 14

Thromboangiitis obliterans (Buerger disease)

Question 15

RTA Type ____

Pathophys: No distal tubular acid secretion
Nephrocalcinosis & nephrolithiasis
U/A: alkalotic urine (high pH) w/ low serum H+ (low pH)
Hypokalmeia
Dx: acid load test
Tx: oral HCO3

Answer 15

RTA Type 1

Question 16

RTA Type ___

Pathophys: No proximal tubular HCO3 absorption
Osteomalacia & rickets
U/A: alkalotic urine w/ deceased urine output
Hypokalmeia
Dx: HCO3 load test (levels stay low)
Tx: volume restriction first; may use HCO3/thiazides

Answer 16

RTA Type 2

Question 17

RTA Type ___

Pathophys: Adrenal/aldosterone deficiency
*Hyperkalemia
U/A: Na excretion (high in urine) w/ K-H retention
Dx: Na restriction (high urinary sodium)
Tx: fludrocortisone

Answer 17

RTA Type 4

Question 18

Adults w/ mild GI s/s and may have unexplained nutritional deficiencies

*Unresponsive Fe-deficiency anemia (repeated anemia refractory to tx)

Anti-endomysial Ab & Anti-tissue transglutaminase antibodies

Answer 18

Celiac disease

Question 19

Anatomical variation that predisposes to AAA & aortic dissection

Answer 19

Bicuspid aortic valve

Question 20

Large stone impacted in cystic duct that externally compresses & obstructs the adjacent common hepatic duct. Results in intrahepatic bile duct dilation w/ obstructive cholestasis (jaundice)

Answer 20

Mirizzi syndrome

Question 21

Prone to arterial/venous thrombus formation b/c of hyper-coaguable state –> can manifest as flank pain & hematuria

Answer 21

Nephrotic syndrome (membranous nephropathy w/ decreased antithrombin III)

Question 22

Bone marrow failure w/ TdT (+) cells; “meningeal leukemia” if relapsed

Tx w/ intrathecal methotrexate

Answer 22

ALL

Question 23

Scleroderma is associated w/ esophageal dysfunction secondary to fibrosis. This defect in either 1) peristalsis or 2) LES function can lead to:

Answer 23

Chronic acid reflux

Question 24

Drug that interrupts the interpretation of EKG during a presentation of ACS b/c it causes non-specific EKG changes

Answer 24

Digoxin

Question 25

New onset ascites in elderly woman

Answer 25

Ovarian cancer (peritoneal carcinomatosis - ovarian mets to peritoneal cavity)

Question 26

Fever, ALTERED MENTAL STATUS, microangiopathic hemolytic anemia, acute renal failure (not severe), thrombocytopenia, PURPURA The drug Quinine associated w/ this

Answer 26

TTP (thrombotic thrombocytopenic purpura)

Question 27

Seen mainly in children/teens after a GI infection w/ E.coli UREMIA (elevated BUN/ammonia), post-infection, SEVERE RENAL FAILURE (high creatinine)

Answer 27

HUS (hemolytic uremic syndrome)

Question 28

Dopamine INHIBITS what hormone?

Answer 28

Prolactin High prolactin/low dopamine (usually drugs) causes decreased GnRH, LH, FSH Oligomenorrhea, gynecomastia

Question 29

Autoimmune disease of cartilage-containing structures (ear, nose, laryngotracheal tree) Laryngotracheal inflammation & destruction leads to tracheal luminal narrowing and peritracheal inflammation, destroying the supportive matrix around the trachea --> COLLAPSE of trachea on expiration is exaggerated (decreased expiratory volume)

Answer 29

Polychondritis

Question 30

Kaposi sarcoma associated with which virus and disease? How does it appear and where?

Answer 30

Human Herpesvirus 8 (HHV-8) AIDS defining disease Multiple violaceous papules on LE, face, oral mucosa, and genitalia

Question 31

Hypoglycemia that eventually causes nocturnal release of GH & cortisol --> causes nocturnal hyperglycemia that causes the increased morning glucose levels Normal physiologic phenomenon

Answer 31

Dawn phenomenon

Question 32

2 causes of acute renal failure (immediate)

Answer 32

``` IV contrast (direct toxicity to renal tubules) IV Acyclovir (causes crystaluria) ``` *Make sure you pre-treat w/ IV fluids before and after these 2

Question 33

Abs that causes delayed renal failure (3 days after starting)

Answer 33

Vancomycin (long volume of distribution if PO)

Question 34

Common causes of pancreatitis

Answer 34

``` Gallstones (female, fat, forty, fertile) EtOH Drugs (sulfas, HCTZ, HIV drugs - look if recently started) ERCP Hypertriglyceridemia (>1000) ```

Question 35

Situations where MUST give IV fluids

Answer 35

Pancreatitis, sepsis, DKA

Question 36

Causes of increased LFTs

Answer 36

``` TYLENOL OD (values in thousands) Acute viral hepatitis (values in hundreds) Shock liver (hypotension and decreased perfusion) ```

Question 37

Contraindicated in ARF, EXCEPT in sclerodermal renal crisis (intra-renal B/L stenosis)

Answer 37

ACEi/ARB

Question 38

Heparin bridging to Coumadin protocol

Answer 38

INR needs to be b/w 2-3 for 2 consecutive days | Need at least 4 days of heparin before D/C it

Question 39

Coumadin-like drugs (Dabigatran, Apixaban, Rivaroxaban) and their effects

Answer 39

Pros: Fewer strokes Fewer major bleeds (joints, brain, eye cavity, spinal) No INR monitoring Cons: More GI bleeds No antidote

Question 40

Sulfa drugs

Answer 40

Disrupt folate pathway --> cause megaloblastic anemia

Question 41

Cocaine-related MI --> contraindication for what drug tx

Answer 41

B-blocker (results in hypertensive crisis)

Question 42

Polymyalgia rheumatica association

Answer 42

Temporal arteritis

Question 43

Transient monocular blindness from ischemia to retinal artery

Answer 43

Amaurosis fugax (associated w/ TIA) Hollenhorst plaques: cholesterol emboli

Question 44

2 common causes of painless, bright red rectal bleeding

Answer 44

Diverticulosis | Angiodysplasia (dilated, slow filling veins in colon wall)

Question 45

6 P's of vascular assessment

Answer 45

Pain, Pallor, Pulseless, Paralysis, Paresthesias, Poikloithermia (cold)

Question 46

Drug causing fibrotic changes in lungs that can mimic cancer nodules & can also cause hypersensitivity pneumonitis

Answer 46

Methotrexate

Question 47

Drugs that increase the QT interval

Answer 47

``` Anti-arrhythmics (Class I & III) Haloperidol, thioridazine Methadone, oxycodone Macrolides Ondansetron Quinolones, metronidazole, HIV drugs ```

Question 48

Pneumonia w/ diarrhea & hyponatremia

Answer 48

Legionnaires

Question 49

Pneumonia w/ hepatitis

Answer 49

Q fever

Question 50

Asthma (allergic rhinitis), eosinophilia, vasculitis

Answer 50

Churgg-Strauss

Question 51

Important formulas

Answer 51

Corrected Na = (Na) + [0.016 x (glucose - 100)] Corrected Ca = measured Ca + [0.8 x (4 - Alb)] Serum Osm = 2(Na) + [Glu/18] + [BUN/2.8] Cockcroft-Gault (Cr clearance) = ([140-age] x wt) / (Cr x 72)

Question 52

Classic Multiple Sclerosis onset of symptoms

Answer 52

Eye/visual problems (ophthalmoplegia) followed by foot/hand paralysis or numbness

Question 53

Metoclopramide s/e

Answer 53

Parkinsonism-like s/s

Question 54

Someone w/ WPW that presents w/ new onset AFib - DOC?

Answer 54

Procainamide

Question 55

Anti-arrhythmic that interacts w/ Coumadin to increase INR?

Answer 55

Amiodarone - must decrease the Coumadin levels

Question 56

Charcot's triad?

Answer 56

3 signs with obstructive ascending CHOLANGITIS 1) fever 2) jaundice (total bilirubin >3) 3) RUQ pain

Question 57

Reynold's pentad?

Answer 57

Severe obstructive ascending cholangitis Charcot's triad + hypotension (shock) & altered mental status (confusion)

Question 58

Side effect of concern w/ nitroprusside? Antidote?

Answer 58

Methemoglobinemia (b/c nitroprusside contains cyanide) | Amyl nitrite sodium nitrite, thiosulfate, hydroxycobalamin

Question 59

What is Todd's paralysis?

Answer 59

Transient focal neurological deficits that occur immediately AFTER a seizure (convulsions w/ intra-oral lesions & in continence) in the post-ictal phase and resolve after this phase NOT a stroke!

Question 60

Why glucagon for B-blocker OD?

Answer 60

Glucagon stimulates the production of cAMP via a pathway that is separate from the pathway that B-receptor activation causes increased cAMP production Excessive B-blockers = decreased cAMP (hypoglycemia, bradycardia, hypotension, hyperkalemia)

Question 61

Type of eating disorder where patient is a "perfectionist" "Young patient who is extremely competitive and high-achieving with a low BMI (< 18.5)

Answer 61

Anorexia Nervosa

Question 62

Only time to use benzo's for delirium?

Answer 62

DT's! | Benzo withdrawal

Question 63

Signs of lead poisoning?

Answer 63

*Purple lines on gingiva (gums) | Foot/wrist drop

Question 64

Antidote for methemoglobinemia?

Answer 64

Methylene Blue *Different than CYANIDE poisoning (also from nitroprusside). The methylene blue converts Fe+3 --> Fe+2 where cyanide you need amyl nitrite to convert the remaining RBC to methemoglobin to bind the CN then give thiosulfate to regenerate the reducing power of glutathione

Question 65

Patient develops dyspnea 2 days after beginning course of antibiotics for pyelonephritis. What is the diagnosis and why?

Answer 65

Acute respiratory distress syndrome (ARDS) --> 1-2 days after Abx are given, if the organism is gram NEGATIVE, the lysis of the bacteria release the endotoxins --> these endotoxins cause pulmonary injury, leading to capillary leakage of fluid into pulmonary interstitial space ("capillary leakage")

Question 66

What CMP component will be increased w/ a GI bleed and why?

Answer 66

BUN --> digested blood in the GI tract is a source of urea

Question 67

Most common cause of testicular torsion?

Answer 67

Bell-Clapper deformity: the anterior portion of testicle is not anchored to the scrotum, allowing for testicle movement Another common cause of torsion is during sleep when the cremaster muscle is active during REM

Question 68

Prehyn's test?

Answer 68

Support the base of testicles and elevate them - if this relieves the testicular pain --> think epididymitis Helps to differentiate between testicular torsion (no pain relief) vs. epididymitis (relief of pain)

Question 69

Highest risk for diabetic foot ulcers?

Answer 69

Diabetic Peripheral Neuropathy MOA: multifactorial and is thought to result from vascular disease occluding the vasa nervorum; endothelial dysfunction; deficiency of myoinositol-altering myelin synthesis and diminishing sodium-potassium adenine triphosphatase (ATPase) activity; chronic hyperosmolarity, causing edema of nerve trunks; and effects of increased sorbitol and fructose. Other etiologies of diabetic ulceration include arterial disease, pressure, and foot deformity.

Question 70

Cushing's triad?

Answer 70

1) Irregular breathing/apnea 2) Increased MAP 3) Bradycardia Suggests marked increase in ICP and impending brain herniation.

Question 71

Earliest indicator of hypovolemia?

Answer 71

Decreased renal output The renal blood flow is decreased as a compensatory mechanism to make blood volume available to the body. Timeline of changes in hypotension: Lower urine output --> + tilt test --> tachycardia

Question 72

What to worry about when treating G(-) infections?

Answer 72

Endotoxins released from lysis of bacteria can cause damage throughout the body E.g. --> endotoxins cause endothelial damage & pulmonary injury --> capillary leakage --> fluid moves from intravascular space into alveolar spaces --> ARDS!

Question 73

What 2 compounds affect iron absorption in duodenum?

Answer 73

Vitamin C = increases iron absorption | Calcium = decreases iron absorption (have to be careful with women taking supplements during pregnancy)

Question 74

Seizures vs Pseudoseizures?

Answer 74

Seizures - Eyes are OPEN - Post-ictal period: confusion & altered mental status - "Floppy" appearance during event Pseudoseizures - Not true seizures, but they are real! - Eyes are CLOSED - No confusion or altered mental status - Immediately after, coherent and alert - During event, "tight" and rigid appearance

Question 75

Low vs High doses of Epinephrine?

Answer 75

Low doses: B+ effects (increased HR/force; vasodilate & decreased TPR or diastolic pressure) High doses: a+ effects (vasoconstrict & increase TPR or diastolic pressure)

Question 76

CO monoxide poisoning - what do you see?

Answer 76

- Suspect more in winter time - Pt has POOR O2 SATURATION, but physical exam is normal (clear airway, no increased breathing effort, no abnormal breath sounds, no discoloration of skin) Tx: 100% O2 continuously

Question 77

Recurrent thromboembolic events (DVT/PE) & recurrent miscarriages?

Answer 77

Antiphospholipid syndrome (APS) - Recurrent small PE's can result in pulmonary HTN --> progressive dyspnea - Anti-phospholipid antibodies present (test w/ Lupus anticoagulant or anticardiolipin ELISA) * Criteria 1) thrombosis in any organ/tissue or pregnancy (miscarriage) 2) persistently positive aPL levels (> 12 weeks apart in testing) - Dermatologic effects: digital cyanosis, livedo reticularis, digital gangrene, leg ulcers - Tx: - Aspirin (inhibit platelet aggregation) - Warfarin (inhibit clotting cascade) - LMWH/aspirin used in pregnancy b/c of teratogenic effects of warfarin - Maintain INR b/w 2-3 FOR LIFE

Question 78

3 types of holosystolic murmurs?

Answer 78

``` Tricuspid regurgitation (radiate to back) Mitral regurgitation (radiate to axilla) VSD ```

Question 79

Cellulitis vs Stasis Dermatitis vs DVT?

Answer 79

Cellulitis: commonly asymmetrical (one leg) * very PAINFUL - hot to touch, pattern of redness is uniform (same height on leg) - increased WBC - Tx: Abx (Keflex - cefalexin) Stasis Dermatitis: result of venous insufficiency (blood pools in lower leg veins & fluid/RBC leak out into surrounding tissues) * ITCHY - Skin looks like cobblestone (bumpy), dry/cracked - Skin sores can appear - Tx: topical steroid cream & ointment DVT * ALWAYS r/o in U/L leg swelling and pain! - Tx: Lovenox and Ultrasound of leg

Question 80

Why is blood ammonia increased during GI bleed?

Answer 80

RBC digestion in the GI tract results in excess hemoglobin breakdown to basic proteins --> this increased nitrogen load is absorbed into bloodstream --> can lead to encephalopathy (confusion, altered mental status, etc)

Question 81

Person presents w/ facial palsy (Bell's palsy) & hearing loss on the same side along with vesicular-like lesions in/around the ear?

Answer 81

Ramsey-Hunt Syndrome - VZV residing in geniculate ganglion (of CN7 & runs next to CN8 in internal acoustic meatus) * Look for vesicles on the outer ear looking like zoster * CN 7-8 involved (facial deficits + hearing loss all on one side)

Question 82

Atypical presentation of MI?

Answer 82

U/L neck pain, nausea, vomiting --> esp in women/diabetics

Question 83

U/L headache that is daily & continuous w/ pain-free periods w/ at least 1 of the following: - conjunctival injection - lacrimation - nasal congestion - rhinorrhea - ptosis - miosis

Answer 83

Hemicrania Continuum *Tx: indomethacin

Question 84

PAINFUL goiter following a URI (viral illness)?

Answer 84

Subacute thryoidits (De Quervain's) Progression: hyperthyroid --> hypothyroid --> euthyroid

Question 85

Characteristics of Papillary thyroid cancer? Characteristics of Medullary thyroid cancer?

Answer 85

Papillary - Psammoma bodies (concentric calcifications) - Orphan Annie bodies (cells appear empty) Medullary - Produce Calcitonin (marker for monitoring)

Question 86

Person with tachycardia, high BP, sweating, anxiety and recently got over an infection or a stressor in their life?

Answer 86

Thyroid storm * Usually follows a precipitating factor --> infection, stress, DKA * Tx: aggressive fluids

Question 87

Purpura is the hallmark of what process?

Answer 87

Leukocytoclastic vasculitis (small vessel vasculitis) Caused by inflammation of small cutaneous vessels --> wall damage and extravasation of RBC into surrounding tissue --> seen as purpura

Question 88

Palpable purpura is hallmark of what 2 infectious processes?

Answer 88

Neisseria meningitis & Rocky Mountain Spotted Fever

Question 89

Why do you get alkalosis w/ taking loop diuretics?

Answer 89

Loops cause excretion of Na (& H2O), K, and Cl in the urine and lower the blood levels --> decreased K+ levels cause the K/H cellular pumps to transport H+ INTO cells and K+ OUT of cells to normalize blood K levels --> the drop in blood H+ levels causes alkalosis

Question 90

What happens to cerebral blood flow with hypercapnia (increased blood CO2) and acidosis?

Answer 90

INCREASED cerebral blood flow

Question 91

Effect on cerebral blood flow w/ hypocapnia (decreased blood CO2) and alkalosis?

Answer 91

DECREASED cerebral blood flow **This is why you hyperventilate to reduce ICP via decreased intracranial blood volume

Question 92

Disease where you have aneurysms (from loss of vaso vasorum) and either oral, ocular, or genital ulcers?

Answer 92

Behcet's disease

Question 93

2 main causes of gout and what test can differentiate the 2 causes?

Answer 93

Overproducer of uric acid Underexcreter of uric acid 24hr urine collection for uric acid levels: If high = overproducer If low = underexcreter

Question 94

What is treatment of choice for acute gout attack?

Answer 94

NSAIDs (indomethacin) or colchicine

Question 95

What is treatment for overproducers of uric acid?

Answer 95

Allopurinol

Question 96

What is treatment for underexcreters of uric acid?

Answer 96

Probenecid (blocks kidney organic anion transporter in PCT --> decreases uric acid reabsorption and increases excretion)

Question 97

What is a concern for probenecid?

Answer 97

Blocks tubular secretion of penicillins, cephalosporins, sulfonamides, indomethacin --> levels will remain increased over longer period of time

Question 98

Painless jaundice w/ non-painful palpable gallbladder. What is it until proven otherwise?

Answer 98

Pancreatic cancer (Courvoisier's sign)

Question 99

Red & tender spots (cords) in superficial veins that come and go in different areas of the body? What association?

Answer 99

Migratory thrombophlebitis (Trousseau syndrome) Pancreatic cancer

Question 100

What antibiotics are NEVER to be used with Coumadin? Why?

Answer 100

Sulfa drugs (Bactrim), Macrolides (except azithromycin) They (-) CYP450 protein and cause an increase in drug levels in the blood

Question 101

What conventional treatment helps eliminate restless leg syndrome?

Answer 101

Tonic water (quinine) --> quinine in it will (-) Mg & Ca flux across the sarcoplasmic reticulum in muscles

Question 102

Autoimmune condition that attacks the skin?

Answer 102

Scleroderma

Question 103

CREST syndrome manifestation of what disease?

Answer 103

Scleroderma Calcinosis (hard calcium deposits in fingers) Raynaud's disease Esophageal dysmotility (will see air-filled esophagus on CT scan) Sclerodactyly (hardening of digits) Telangectasias (capillaries near skin surface causing discoloration)

Question 104

Explain graft vs host disease?

Answer 104

Immunologically-driven reaction from transplant of one person's immunologically-active (immune cells are present in that tissue) tissue (bone marrow) into someone who is immunosuppressed b/c of treatment to prevent host from rejecting the graft. However, the graft's immune cells proliferate and attack host cells. Mortality around 20%

Question 105

Sclerosing cholangitis has higher incidence of what cancer? What is Klatskin tumor?

Answer 105

Cholangiocarcinoma (bile duct cancer) Klatskin: subtype of cholangiocarcinoma that forms at confluence of R & L hepatic bile ducts and causes obstruction of bile outflow, leading to contracted gallbladder

Question 106

Before Rx-ing erectile dysfunction meds (Sildenafil, etc), what other drug must you ask about and is a contraindication?

Answer 106

Nitrates!! (blood pressure or angina) *Cause large drop in blood pressures!

Question 107

Progressive neurological disease involving upper and lower motor neurons - usually gradual onset of asymmetric weakness of distal limb?

Answer 107

Amyotrophic Lateral Sclerosis (ALS)

Question 108

Middle age woman on several medications for blood pressure control presents to ER w/ gradually increasing blood pressure readings. Her normal pressures are around 115/75. Current BP is 210/115. CT shows narrowing of renal arteries. What is the cause?

Answer 108

Fibromuscular dysplasia

Question 109

Causes of new-onset atrial fibrillation?

Answer 109

``` HEMP Hyperthyroidism EtOH (chronic EtOH or acute EtOH intoxication) Mitral stenosis (rheumatic fever) PE ``` CAD, CHF, MI, pneumothorax

Question 110

Pearly pink nodules/papules related to sun exposure often seen on hands, face, neck?

Answer 110

Basal cell carcinoma - spreads laterally then vertically - rarely spreads beyond primary site

Question 111

Precursor lesion for squamous cell carcinoma?

Answer 111

Actinic keratosis

Question 112

5 characteristics of melanoma?

Answer 112

``` ABCDE Asymmetrical shape Border irregularity Color variation Diameter >6mm Elevation ```

Question 113

What iatrogenic condition can result in locked-in syndrome?

Answer 113

Central pontine myelinolysis from rapid correction of hyponatremia --> want around 10 mEq/24hrs Compete paralysis of voluntary muscles in all parts of the body EXCEPT for those that control eye movement

Question 114

Male patient has increasing weakness of his urine stream and in last 24 hrs has not urinated at all. He is very uncomfortable and when a catheter is attempted, it meets resistance w/ no urine discharge. Blood starts oozing from the catheter. What do you do next?

Answer 114

Suprapubic tube placement --> percutaneous bedside technique under ultrasound guidance Used to relieve urinary retention w/ bladder outlet obstruction & possible hydronephrosis

Question 115

What test should always be done to male w/ acute onset testicular pain? Why?

Answer 115

Doppler ultrasound to r/o testicular torsion

Question 116

45 yo male w/ low back pain radiating to scrotum, dysuria, and pain of defecation. Tried several courses of Abx, w/ symptoms recurring 1 week after stopping each therapy. On rectal exam, prostate is enlarged w/ areas of tenderness and fluctuance. What is it?

Answer 116

Prostatic abscess *Suspect when a man develops repeated UTI's w/ improve w/ Abx, but recur after therapy ends. ***Presence of fluctuant mass in prostate = prostatic abscess

Question 117

What is Morton neuroma?

Answer 117

Enlarged nerve located in foot's 3rd interspace b/w 3rd & 4th toes --> diagnosis made by eliciting extreme pain on palpation in that area. Look for woman w/ high-heeled shoes, standing in them all day

Question 118

88 yo male w/ findings consistent w/ localized prostate cancer, but has multiple overlying comordibities. What is next best step in mgmt?

Answer 118

NO intervention --> no PSA, no biopsy, nothing Disease-specific survival rates for localized prostate cancer at 10 years was 83% for those who did NOT receive therapy --> with his multiple other comorbidities, he may die from those instead of prostate cancer

Question 119

Vague RUQ discomfort w/ recent wt loss in a 60 yo alcoholic woman w/ cirrhosis from Hep C. What are you thinking? What blood marker is most helpful?

Answer 119

Hepatocellular carcinoma --> increased aFP (correlates w/ tumor size) *Solitary tumor in liver w/ RUQ discomfort + wt loss

Question 120

In someone with bladder cancer, what is a feared complication?

Answer 120

B/L hydronephrosis *Think bladder cancer in pts w/ hx of smoking, urinary obstruction (leading to hydronephrosis), and/or hematuria

Question 121

Treatment for temporal arteritis? What is a common association?

Answer 121

Corticosteroids Polymyalgia rheumatica

Question 122

Why does serum Na drop during prolonged vomiting or diarrhea?

Answer 122

GI tract fluids have Na concentration similar to plasma; as these fluids are lost (vomiting or diarrhea), the Na levels will drop due to lack of absorption from GI tract --> these fluids should be replaced w/ isotonic, Na-containing fluids. However, most people drink water (hypotonic) --> the body retains this water b/c of its volume depletion --> results in dilutional hyponatremia Dilutional hyponatremia --> when isotonic fluids are lost (vomiting/diarrhea) and replaced by hypotonic (water) fluids.

Question 123

81 yo found on living room floor. Last seen 3 days ago. Obtunded but breathing spontaneously and hemodynamically stable. Temp 100.7 w/ tender, tense R calf. K 5.9, BUN 88, Cr 3.5, lactic acid 2.6, CK 7,200, WBC 17,000. What does he have? What is appropriate mgmt?

Answer 123

Rhabdomyolysis (immobilized position, elevated CK): from pressure injury & can cause ARF * CK and hyperkalemia --> from crush injury leading to leakage of K, CK, & myoglobin out of cells into blood --> myoglobin precipitated in kidney tubules & changes into acid hematin leading to renal failure * Urgent hemodialysis

Question 124

Indications for urgent hemodialysis?

Answer 124

AEIOU A: acidosis (severe) E: electrolytes (hyperkalemia) I: intoxication w/ nephrotoxic substances (ethylene glycol) O: overload (fluid in renal/CHF patients) U: uremia (mental status changes or pericardial effusion)

Question 125

How do you prevent rhabdomyolysis-induced renal failure?

Answer 125

IV fluids + Alkalization of urine w/ NaHCO3 (sodium bicarb) --> facilitates excretion of myoglobin, preventing tubular injury

Question 126

24 yo suffered subarachnoid bleed from ruptured aneurysm 4 days ago and is now recovering. He Na level is gradually decreasing despite being on fluid restriction. He is clinically euvolemic, but has high urine osmolality & specific gravity w/ salt wasting, elevated fractional excreted Na and total urinary sodium level. What is the cause? What is appropriate tx?

Answer 126

Syndrome of inappropriate ADH release (SIADH) - Occur in patients w/ recent head trauma or major CNS procedure - Assn w/ small-cell carcinoma of lung (ectopic ADH production) - Clinical euvolemic - High urine osmolality (concentrated) - Fractional excretion of Na is high (water w/o salt is retained) Tx: ADH (-) --> demeclocycline, lithium

Question 127

58 yo woman found to have elevated serum Ca and parathyroid hormone. She is asymptomatic and does NOT want elective surgery but rather close medical f/u. What therapy should she start?

Answer 127

Most likely parathyroid adenoma --> only cure is surgery Tx: Estrogen-progestin tx helps in post-menopausal women w/ primary hyperparathyroidism - Estrogen-progestin helps reduce bone resorption & thus increase bone density and possibly decrease serum Ca levels

Question 128

Painless sore on glans of penis --> rough surface that began to enlarge to develop into painless ulcer. 2 new sexual partners in past year w/ no protection. Small, palpable lymph nodes felt in his inguinal area B/L. VDRL (-). What is it?

Answer 128

Squamous cell carcinoma of penis *First symptom of penile cancer = painless, exophytic growth --> ulcerated nodule or a flat ulcer that does not heal but enlarges progressively. If not response to conservative tx, need to confirm w/ biopsy.

Question 129

Describe Menetrier's disease. What 4 side effects are often seen?

Answer 129

Excess mucus production in the stomach 1) Protein-losing enteropathy (low albumin, edema) 2) Hypertrophy of gastric rugae 3) No gastric acid production 4) Diarrhea

Question 130

Patient presents w/ watery diarrhea of sudden onset. Colonoscopy is normal and histopathology of colon biopsy reveals significant lymphocytes. What is the diagnosis?

Answer 130

Microscopic colitis --> normal appearance but inflammatory cells on histology Assn w/ autoimmune diseases, drugs (PPI, H2(-), NSAIDs) Tx: corticosteroids

Question 131

What is Marjolin's ulcer?

Answer 131

Aggressive ulcerating SCC that results from long-term, continuous mitotic activity as epidermal cells attempt to resurface the open deficit --> becomes a malignant transformation of a chronic wound Slow growing, painless, and no lymphatic spread due to destruction of local lymphatics **Seen in BURNS, osteomyelitis ulcer, venous stasis ulcer, chronic inflammation, scarred skin

Question 132

Describe characteristics of seborrheic keratosis

Answer 132

``` Benign Painless Yellow/brown and greasy in appearance Warty-like "Stuck-on" appearance ``` Autosomal dominant

Question 133

What medication can help reduce the systemic response of hyper metabolism and increased catecholamine release due to SIRS/sepsis?

Answer 133

Propranolol --> B-adrenoreceptors responsible for increased catabolism and reaction to stress

Question 134

Which laboratory sign is an indicator of severe sepsis?

Answer 134

Hyponatremia

Question 135

What is a ganglion cyst? What is treatment? If removing it, what part is crucial to removal or it will reappear?

Answer 135

Non-neoplastic soft tissue lump most often on/near joints and tendons of hands or feet. Formed from sheaths of collagen from joint space and communicates w/ joint space via pedicle Tx: 50% resolve spontaneously If surgically removing it, need to remove the pedicle!

Question 136

What is a carcinoma? What are its 2 subtypes?

Answer 136

Malignant neoplasm of epithelial origin or internal/external lining of body 1) Adenocarcinoma --> glandular origin 2) Squamous cell --> squamous epithelium

Question 137

What is sarcoma? Treatment of choice?

Answer 137

Cancer originating from mesoderm (bones, tendons, cartilage, muscle, fat - the supportive & connective tissue) Tx: Wide-margined excisions w/ keeping patients functional reserve in mind (using that area after removal)

Question 138

Diagnostic of choice for any soft tissue mass?

Answer 138

MRI --> analyze surrounding tissue

Question 139

What are most common EKG findings for PE?

Answer 139

Non-specific ST-segment & T-wave changes

Question 140

What EKG finding is pathognomonic for R-heart failure, usually from large PE?

Answer 140

S1Q3T3 S waves in Lead 1 Q waves in Lead 3 Inverted T waves in Lead 3

Question 141

Common side effect of steroids that are often overlooked?

Answer 141

Steroid-induced Psychosis!

Question 142

Why are chronic steroids such an issue, especially during surgery?

Answer 142

Chronic steroid use causes (-) of HPA axis by (-) CRH & ACTH secretion --> (-) cortisol made by adrenals --> adrenals shrink due to low production --> during times of stress (surgery), they can't produce the high quantity of steroids needed Results in shock (low BP, tachycardia)

Question 143

Pt presents w/ chronic history of intermittent episodes of severe, crushing chest pain radiating to back and jaw lasting from seconds to minutes. Pain accompanied w/ dysphagia triggered by ingestion of certain foods. Cardiac workups have been negative. What 2 diagnoses are clinically indistinguishable and what further test will differentiate them?

Answer 143

Diffuse esophageal spasm & Nutcracker esophagus *Manometry* DES: high-intensity disorganized contractions w/ NORMAL resting LES pressure Nutcracker: INCREASED resting LES pressure

Question 144

Young female (20-30's) smoker is wanting protection from getting pregnant. She receives a course of oral contraceptive pills from her OBGYN. Several days/months later, she develops one-sided leg pain and swelling. It hurts to touch her leg & when she lifts her foot up towards the sky. What is it?

Answer 144

DVT!!!! *This presentation is pathognomonic for USMLE* Young female Smoker OCP's *One-sided calf pain, tenderness, (+) Homans sign (+/- leg edema)

Question 145

What pathogen causes infection in lymphatics leading to chronic fibrosis w/ non-pitting lymphedema?

Answer 145

Wuchereria bancrofti --> filariasis

Question 146

Bruit heard near groin (one side) & patient has a high resting HR. Progressive one-sided leg swelling has occurred over several months. What is it? What medical history component is a common preceding incident?

Answer 146

Femoral arteriovenous malformation * Hx of penetrating trauma --> leads to AV malformation * Groin bruit + high resting HR = femoral AVM

Question 147

What is overflow/stress incontinence? What is best initial treatment? Why not 5a-reductase (-)?

Answer 147

Large prostate causes outlet obstruction and traps a large amount of urine in the bladder. The involuntary urine loss (during cough, sneeze) occurs when bladder pressure > urethral pressure. Tx: alpha-blocker (doxazosin, terazosin, tamsulosin) --> these RELAX the sphincter, allowing easier voiding 5a-reductase (-) --> takes a LONG TIME to act (up to FULL YEAR) so not appropriate for immediate relief

Question 148

What is urge incontinence? Appropriate initial tx?

Answer 148

Bladder hyperactivity causing frequent bladder emptying --> NO warning w/ sudden urge to urinate & can't hold it Tx: anti-spasmodics (oxybutynin & tolterodine) --> help relax the detrusor muscle

Question 149

Same day after surgery, a smoker develops fever. What is most likely cause? What is treatment?

Answer 149

Day 1 Post-Op Fever = Atelectasis! Incentive spirometry to improve ventilation via deep breathing, coughing

Question 150

Man presents to ER after being struck by a car. He has a subarachnoid hemorrhage and has to be intubated. The next day develops bradycardia, BP of 130/80, and is not over breathing the ventilator. What is next appropriate step in mgmt?

Answer 150

*Reduce intracranial pressure Least invasive first: - Raise head of the bed - Sedation w/ propofol - Hyperventilation (PaCO2 30-35) - Mannitol (osmotic diuretic) *Cushing triad: bradycardia, hypertension, irregular respiratory pattern

Question 151

What is Cushing's triad & when is it seen?

Answer 151

1) Bradycardia 2) Hypertension (relative) 3) Irregular breathing pattern *Seen w/ increased ICP

Question 152

Progressive dysphagia to both solids and liquids w/ a massively dilated proximal esophagus & narrowed, tapered distal esophagus on barium swallow. What is it? What is pathophys? What are 3 other associations w/ it?

Answer 152

Achalasia: failure of LES to relax due to loss of inhibitory neurons (nitrous oxide releasing neurons) in LES Most idiopathic, but other associations: - Chagas disease (reduviid bug) - Lymphoma - Gastric carcinoma * NO progression pattern to solids then liquids (seen in esophageal carcinoma) * Barium swallow --> "bird's beak" (proximal dilation of esophagus w/ narrowed lower esophagus)

Question 153

What 3 tests are performed for workup of a prostate nodule?

Answer 153

1) DRE 2) PSA levels 3) Biopsy (want histologic diagnosis & Gleason score) Do biopsy when: - Can't distinguish b/w a cyst - Can't distinguish b/w benign or cancerous condition - Staging * Gleason score - grading system determined by cellular features of prostate cancer cells that correlates w/ clinical behavior) - Higher score = greater likelihood of spread outside of prostate

Question 154

What is initial drug choice for treatment of BPH? What is next step in therapy if the first choice drug fails?

Answer 154

1st choice: a-adrenergic (-) - tamsulosin, doxazosin 2nd choice: 5a-reductase (-) - finasteride, dutasteride - blocks intracellular conversion of testosterone to DHT and shrinks hyperplastic prostate tissue & helps reduce progression of BPH

Question 155

Unmonitored use of blood thinners can cause coagulopathy & worsen a GI bleed. What is the first & second steps in management?

Answer 155

1st step: hemodynamic stability --> transfusing blood pdts 2nd step: reversal of elevated INR *Acute setting = FFP *Prolonged effects on clotting cascade = Vitamin K

Question 156

Patient presents w/ blood in the stool, high ALP, high total bilirubin, and anemia. What should you consider? Next best step(s)?

Answer 156

Duodenal tumor obstructing common bile duct (Ampulla of Vater) 1) Upper abd ultrasound --> shows dilated intra & extra hepatic ducts 2) Upper endoscopy to confirm suspicion 3) Biopsy tissue

Question 157

Pt with protracted diarrhea recently develops jaundice and has high ALP and total/direct bilirubin levels. RUQ ultrasound shows strictures and dilations of intrahepatic & extra hepatic ducts. What is it? What 2 types of cancer is this patient most at risk for?

Answer 157

Primary sclerosing cholangitis (PSC) * Seen w/ Inflammatory Bowel Disease (Ulcerative Colitis) - Look for intermittent cramping & bloody diarrhea Cholangiocarcinoma & colon cancer

Question 158

66 yo woman who underwent laparotomy 1 week ago recently develops chest pain, shortness of breath, & has head and neck vein distention. Her vitals show tachycardia, tachypnea, and a loud S2. His ABGs find hypoxemia and hypocapnia and EKG is normal. What is next best test?

Answer 158

Spiral CT scan - Heparin is better option before CT scan Massive PE causes cor pulmonale --> seen by hypotension & neck vein distension. * Risk factors for PE: - Orthopedic surgeries - Hypercoagulable states (OCPs, Factor V Leiden mutation, antithrombin III deficiency) - Prolonged immobilization - Malignancy

Question 159

What is most appropriate step of someone w/ longstanding GERD?

Answer 159

Endoscopy w/ biopsies * Anyone w/ epigastric pain, older than 45 yo, (+) stool guaiac, wt loss, or dysphagia/odynophagia --> needs endoscopy and biopsies - Mucosal biopsies in stomach for H. pylori

Question 160

Man w/ chronic pancreatitis has LUQ pain & has no jaundice or spider angiomata. Abdomen is NT, ND, no caput medusa. The spleen tip is palpable. Upper endoscopy shows profound gastric varices but no esophageal varies. What is diagnosis?

Answer 160

Splenic vein thrombosis Well described complication of chronic pancreatitis --> splenic vein runs along posterior surface of pancreas & adjacent inflammation can eventually induce thrombosis Gastric varices seen b/c gastric mucosa vessels drain into an obstructed splenic vein NO esophageal varices

Question 161

Woman presents w/ fever & chills, RUQ pain and jaundice. She had a laparoscopic cholecystectomy 3 months ago. Her ALP and direct bilirubin are very high. Ultrasound shows extremely dilated intrahepatic ducts but common bile duct can't be visualized. What is most likely diagnosis?

Answer 161

Iatrogenic stricture of common bile duct Look for biliary colic & obstructive jaundice (high ALP & direct bilirubin) CBD strictures get infected and cause cholangitis --> look for Charcot triad (fever/chills, RUQ pain, jaundice)

Question 162

72 yo Norwegian w/ contracted hand that can't be extended or placed flat on a table. It has developed gradually over many years. Palpable fascial nodules are present. What is it?

Answer 162

Dupuytren contracture: palmar fascial disease resulting in shortening & thickening of fibrous bands in hands/fingers Seen in older men of Scandinavian descent

Question 163

Best treatment for acute prostatitis? What bugs cause it?

Answer 163

E. coli, Chlamydia *Fluoroquinolone (ofloxacin) covers both E. coli & Chlamydia --> need for 4-6 weeks to ensure adequate levels of drug in prostate

Question 164

Risk factors for gallstones? Best test to confirm/look for gallstones?

Answer 164

5 F's --> Fat, Fertile (kids), Forty, Female, Fair Ultrasound of RUQ

Question 165

Best initial treatment for hemorrhoids?

Answer 165

Conservative: sitz baths, local anesthetics, high-fiber diet, lots of fluids

Question 166

For herniated spinal disc, what is initial imaging study and treatment? Always assess what with disc herniation?

Answer 166

Imaging --> MRI Tx: pain control w/ resolution overtime **Always assess bowel/bladder function for emergency cauda equina syndrome

Question 167

(+) fecal occult blood in adult >40 yo?

Answer 167

Cancer until proven otherwise

Question 168

How does L-sided colon cancer present?

Answer 168

Obstructive symptoms --> changes in stool caliber, constipation overtime, bright red blood covering stools, wt loss

Question 169

First treatment option for BPH? Second treatment option?

Answer 169

1st: a1 blocker (tamsulosin) --> acts on bladder trigone & urinary sphincter - S/e: orthostatic hypotension 2nd: 5a-recductase (-) (finasteride) --> blocks conversion of testosterone to dihydrotestosterone in the prostate --> DHT responsible for hormone-dependent enlargement of the prostate

Question 170

Does Hgb or Hct change during acute blood loss?

Answer 170

NO --> Hct or RBC count only decreases as fluid from other body sources (ECF) enters intravascular space in response to a decreased intracapillary blood pressure. This takes about 4-6 hours for normalization to occur If IV fluids are given, this causes a dilutional effect and Hct may decrease

Question 171

Man w/ intermittent abdominal cramps and bloody diarrhea over past 8 years has a relapse of diarrhea and takes loperamide to control diarrhea. He develops severe abdominal pain in epigastric area over past 12 hours. Xray shows massively distended transverse colon w/ gas in the colon wall w/ no air under the diaphragm. What is the diagnosis?

Answer 171

Toxic megacolon --> acute distended colon w/ wall ischemia and pneumatosis intestinal (coli) - hx of intermittent abdominal cramps w/ bloody diarrhea = ulcerative colitis *Fever, leukocytosis, and abd distension on imaging **Toxic megacolon is complication of UC

Question 172

5 triggers that can induce toxic megacolon?

Answer 172

``` Hypokalemia Opiates Anticholinergics Loperamide Barium enema ```

Question 173

Solitary, painless testicular mass in 20 yo man on histology shows small cells w/ crowded nuclei, high mitotic rate, & necrosis. Enlarged retroperitoneal nodes are seen. aFP is elevated. What type of cancer is it?

Answer 173

Embryonal carcinoma

Question 174

What marker is elevated in choriocarcinoma? What marker is elevated in seminoma? Yolk-sac tumor?

Answer 174

* b-HCG - cytotrophoblastic & syncytiotrophoblastic cells resembling chorionic villi * Placental alkaline phoshpatase (PLAP) - centrally-placed nuclei & nucleoli resembling primary spermatocytes * aFP - papillary structures resembling glomeruli (Schiller-Duval bodies)

Question 175

Intense burning pain that occurs after an injury that is not relived w/ analgesics - what is probable diagnosis? If so, what is diagnostic test to confirm?

Answer 175

CRPS or reflex sympathetic dystrophy (RSD) * Do sympathetic block --> if it relieves the symptoms, RSD is confirmed * Surgical sympathectomy will cure RSD

Question 176

Smoking & drinking history are very important for what type of cancer?

Answer 176

Squamous cell carcinoma

Question 177

Progressively growing, painless lymph node mass in the absence of systemic symptoms must be evaluated for what type of cancer in person w/ smoking and drinking history & poor dental hygiene? Next best step in diagnosis?

Answer 177

Metastatic squamous cell carcinoma --> arising from somewhere in respiratory or digestive tract Next step: triple endoscopy (laryngoscopy, endoscopy, bronchoscopy) w/ mucosal biopsies to determine primary site of cancer *Painless neck masses in older patients are considered cancer until proven otherwise!

Question 178

28 yo woman w/ vague RUQ pain suddenly gets much worse and she becomes hypotensive, tachycardic and vomits. Her abdomen is mildly distended and diffusely tender. Hgb is 8.1 and abd x-ray shows no evidence of pneumoperitoneum. She denies pregnancy b/c she takes her OCPs daily and last menstrual period was normal. What is the cause of her acute illness?

Answer 178

Ruptured hepatic adenoma * OCPs huge risk for hepatic adenoma in women b/w 20-40 yo - Risk = dosage & duration of estrogen use - Will spontaneously regress when stop taking OCPs *Sudden RUQ pain + hypotension with OCP use CT scan is diagnostic Cold spots on sulfer colloid liver scan

Question 179

Risks for hepatic adenomas?

Answer 179

``` OCP use Glycogen storage disease type 1 Anabolic steroids (body builder) ```

Question 180

Sudden onset erectile dysfunction w/ presence of nocturnal erections?

Answer 180

Psychogenic cause of problem

Question 181

Flank pain that radiates to inner thigh and scrotum w/ hematuria. What is diagnosis until proven otherwise? Best initial test?

Answer 181

Nephrolithiasis (kidney stone) Diagnostic test: 1) plain x-ray (calcified stones will be visible) 2) If not, CT scan w/o contrast

Question 182

Besides strictures and fistulas, what is another complication of Crohn's disease? What is mechanism behind this?

Answer 182

Nephrolithiasis (kidney stones) Calcium normally binds oxalate from diet in the intestine --> in Crohn's, fat malabsorption (disease of terminal ileum - site of fat reabsorption) results in increased intra-luminal fat that binds all the Calcium in the intestine --> oxalate (normally bound by calcium & excreted) is now absorbed by body and precipitates in higher concentrations in the kidneys --> stones

Question 183

Elderly and alcoholics are at risk for what cerebral complication? Why?

Answer 183

Subdural hematomas Brain volume decreases over time in both elderly & alcoholics --> minimal trauma causes brain to "rattle around" & tear bridging veins *Sudden "senility" in previously health person w/ hx of trauma --> suspect subdural hematoma

Question 184

Name complications of Neurofibromatosis Type 1 (von Recklinghauen disease)?

Answer 184

Pheochromocytoma Pigmented iris hamartomas "cafe-au-lait" spots

Question 185

Person w/ history of neurofibromatosis type 1 presents w/ LLQ abdominal mass. He is found to have metabolites of epinephrine & norepinephrine in 24-hour urinary collection. What do you suspect? Next best test?

Answer 185

Pheochromocytoma MRI scan of his adrenal glands to confirm pheo

Question 186

How to differentiate b/w extra-adrenal or adrenal focus of pheochromocytoma?

Answer 186

If Epinephrine metabolites are present in urine --> adrenal origin Epi not made outside the adrenal glands

Question 187

Most common cause of double vision in adults over 40 yo?

Answer 187

Graves disease

Question 188

Which is more of an emergency - periorbital or orbital cellulitis and why? What are signs to watch for?

Answer 188

Orbital cellulitis (post-septal) --> infection behind orbital septum (posterior boundary of eyelids that are directly in front of the corneas)

Question 189

Which is more of an emergency - periorbital or orbital cellulitis and why? What are signs to watch for?

Answer 189

Orbital cellulitis (post-septal) --> infection behind orbital septum (posterior boundary of eyelids that are directly in front of the corneas) *Proptosis, eye pain on movement, vision loss, visual acuity changes, fever Look for hx of recent sinusitis or tooth infection

Question 190

When using TMP-SMX (Bactrim), aside from Coumadin, what other drug should you NOT use? What side effect do you worry about?

Answer 190

Spironolactone *Increased risk of HYPERKALEMIA when used together

Question 191

What 3 conditions (2 genetic 1 renal) must you consider when dealing w/ subarachnoid hemorrhage?

Answer 191

Ruptured aneurysms Marfan syndrome Ehlers-Danlos syndrome ADPKD

Question 192

Describe Paget's disease of the bone (osteitis deformans)? What symptoms might you see as initial s/s? Common lab findings?

Answer 192

Initial osteoclast overactivity (bone breaks down) --> accelerated osteoblast activity in effort to rebuilt drastically reduced bone matrix --> results in structurally inferior woven bone --> bone starts to bow & fracture easily S/S: - Pain (from bowing/fracture of long bones secondary from arthritis) * Headaches --> see below * CN palsies --> see below * Hearing loss --> damage of cochlear nerve from enlargement of temporal bone & narrowing of internal auditory meatus Lab findings *High ALP, normal Ca, normal Phos

Question 193

Describe respiratory quotient (RQ) & normal values for different sources of fuel?

Answer 193

Steady-state ratio of CO2 produced to O2 consumed per unit time *Used to make assessments of metabolism *Normal RQ = 0.8 (mix of carbs, fats, proteins) Carbohydrate diet only = 1.0 Proteins only = 0.8 Oxidation of fatty acids only = 0.7

Question 194

Acute pain & swelling over coccyx that never happened before?

Answer 194

Pilonidal cyst --> infection of midline sacrococcygeal skin & sub-Q tissues *Dermal sinus tract originating over the coccyx

Question 195

Describe important features of epidural hematoma?

Answer 195

- Rupture of middle meningeal artery as it exits from foramen spinosum - Blood in the potential space b/w cranium & dura mater - Presents as unconsciousness followed by lucid interval; followed by gradual deterioration of consciousness w/ symptoms of elevated ICP (headaches, N/V) - May have dilation of pupil on same side (CN3 compression) - May have contralateral hemiparesis - Biconvex hematoma that does NOT cross the suture lines

Question 196

What are some common associations with undifferentiated nasopharyngeal carcinoma? How do patients present?

Answer 196

Viral infections (EBV) Middle East/Far East descent Smoking Nitrosamine consumption (salted fish) S/S: Recurrent OM Recurrent epistaxis Nasal obstruction

Question 197

Man w/ constant & gnawing epigastric pain that is worse at night, anorexia w/ wt loss, & painless jaundice. What do you suspect? What are other signs you may see?

Answer 197

Pancreatic cancer *Smoking big risk factor S/S: - Jaundice (common bile duct blockage) - Steatorrhea (inability to secrete fat-digesting enzymes or blockage from main pancreatic duct) - Epigastric pain (insidious, gnawing, worse at night) - Painless jaundice - Wt loss & fatigue - Migratory thrombophlebitis (Trousseau sign)

Question 198

32 yo woman w/ intermittent blood staining her bra from L breast. No breast masses or axillary lymphadeonpathy noted and ultrasound is normal. What is it?

Answer 198

Intraductal papilloma *Most common form of intermittent bloody discharge from one nipple in PERImenopausal women

Question 199

In a person w/ a joint replacement, a subacute (months after) presentation of joint pain w/ increased WBC most likely points to what bug?

Answer 199

Staph epidermidis

Question 200

What are 4 T's of anterior mediastinal masses?

Answer 200

Thymoma Teratoma (other germ cell tumors) Thyroid neoplasm Terrible lymphoma

Question 201

Triad for mononucleosis? These patients will develop rash w/ what type of Abx? Best initial tests to confirm?

Answer 201

Fever, sore throat, lymphadenopathy B-lactams (-cillins, cephalosporins) Heterophile antibody test & CBC

Question 202

Drug side effects on respiratory system. What naturally causes bronchodilation? Propranolol? Enalapril?

Answer 202

Beta stimulation/anti-ACh = bronchodilation Propranolol --> non-specific B-blocker that causes bronchoconstriction --> WHEEZES Enalapril --> ACEi causes dry COUGH

Question 203

Patient w/ HIV presents w/ fever and bleeding from site of recent IV drug use. She has confusion and tingling sensation her her arms and legs for past 2 hours. She has scleral icterus and non palpable purport on her chest and arms. Labs showed anemia, low WBC, low platelets, increased bleeding time, proteinuria, hematuria, and fragmented RBC on peripheral smear. What is it?

Answer 203

Thrombotic Thrombocytopenic Purpura (TTP) Pentad 1) Fever 2) Thrombocytopenia (low platelets, petechiae, excessive bleeding from punctured site) 3) Microangiopathic hemolytic anemia 4) Neurologic symptoms (confusion, paresthesias) 5) Renal failure (proteinuria, hematuria)

Question 204

How to differentiate TTP from DIC?

Answer 204

TTP --> NO changes in PT or PTT | DIC --> coagulation factors consumed (INCREASED PT/PTT)

Question 205

Best therapy for chemotherapy-induced N/V?

Answer 205

If unresponsive to promethazine, try triple therapy: 1) Serotonin blocker --> ondansetron, "-setron" 2) Dexamethasone 3) Substance P/neurokinin 1 receptor blocker --> Fosaprepitant

Question 206

Which ulcer IMPROVES with eating? Which ulcer WORSENS with eating?

Answer 206

IMPROVES = duodenal (HCO3 secreted helps ulcers) WORSENS = gastric (acid secreted w/ meals irritates ulcers)

Question 207

Testicular tumor causing erectile dysfunction and gynecomastia. Cells show eosinophilic cytoplasm, bland nuclei, and small crystalline cytoplasmic inclusions. What is the type of cancer. What are the crystals called?

Answer 207

Leydig cell tumor - Produce excess androgens (may be converted to estrogens by peripheral aromatization) - This is what causes erectile dysfunction/gynecomastia Reinke crystals

Question 208

In adrenal mass found on imaging, what are 2 most important steps?

Answer 208

1) Benign vs malignant --> radiologic features 2) Functional (secreting hormones) vs nonfunctional - 24hr urine catecholamine/metanephrine screen - Serum aldosterone-to-renin ratio - Low dose dexamethasone suppression test

Question 209

Sources for brain abscess?

Answer 209

Sinusitis Tooth abscess OM Mastoiditis

Question 210

20 yo w/ persistent headaches & fever for 1 wk who just had a seizure. He is obtunded. Imaging shows ring-enhancing lesion in R frontal lobe and an air-fluid level in the R frontal sinus. What is most likely organism(s)? What is it?

Answer 210

a-hemolytic Streptococcus + mixed anaerobes Brain abscess in frontal lobe --> associated w/ sinusitis

Question 211

22 yo African American male receives vaccinations and travel meds for trip to India. He became fatigued and has mild jaundice now. Developed severe abd pain after starting prophylactic meds. Urine is darker, jaundiced, new heart murmur, and palpable spleen tip. What is the cause? What is the inheritance pattern?

Answer 211

``` G6PD deficiency *Chloroquine (malaria prophylaxis) Certain drugs (Sulfa drugs, antimalarials), foods (fava beans) ``` X-linked RECESSIVE (also Hemophilia A + B)

Question 212

Someone develops sudden onset LE weakness after recovering from GI infection 5 days ago. Has paresthesias in hands and feet. Becomes obtunded and needs intubation. Why?

Answer 212

Guillian-Barre syndrome causes ASCENDING paralysis that can affect muscles of respiration!

Question 213

26 yo man has back pain that is worse at night and began near his sacrum. Pain starting to creep up his back and gets a little better with activity. What must you consider? What is treatment?

Answer 213

Ankylosing Spondylitis --> "bamboo spine" on imaging Tx: anti-TNFa agents (etanercept, infliximab) Can use NSAIDs for some relief

Question 214

Only treatment options for COPD that decrease morbidity and mortality?

Answer 214

Smoking Cessation | O2 therapy

Question 215

What drug should be given to someone w/ a history of recent MI?

Answer 215

B-blocker (decreases myocardial O2 demand by decreasing HR - this increases diastole and coronary artery perfusion time)

Question 216

What are you thinking in a person w/ EKG changes showing ST-segment elevation in leads II, III, aVF? Symptoms?

Answer 216

Inferior wall infarct/R ventricular infarct --> R coronary artery Symptoms: hypotension, tachycardia, lungs clear, ABSENCE of pulses paradoxus

Question 217

How to distinguish R ventricular infarct vs cardiac tamponade?

Answer 217

Pulsus paradoxus Tamponade: both ventricles already compressed -> during inspiration, venous return increases to R ventricle --> excess filling and expansion of R ventricle that further compresses and displaces the L ventricle --> LV ejection fraction and contraction very low and causes low systolic BP during inspiration R vent infarct: heart not being compressed and any increase in RV volume is accommodated by pericardial sac

Question 218

Treatment for R ventricle infarction?

Answer 218

IV fluids --> volume loading of R ventricle causes it to contract more forcefully (Sterling's law - more in, more out)

Question 219

How to differentiate b/w central vs nephrogenic diabetes insipidus?

Answer 219

Dilute urine w/ frequent urination Central: no ADH release from pituitary --> kidney is fine & will respond to exogenous ADH/vasopressin by increasing H2O reabsorption and concentrating the urine (increased urine osmolality) Nephrogenic: ADH secreted from pituitary -> kidney INSENSITIVE to its effect --> exogenous ADH/vasopressin does NOT cause significant rise in urinary osmolality (urine remains dilute!)

Question 220

What medication is indicated in mgmt of acute asthma attacks?

Answer 220

Steroids (oral or IV)

Question 221

Vomiting w/ upper GI bleeding - suspect what?

Answer 221

Mallory-Weiss tear

Question 222

Best mgmt for 2nd degree Moritz Type II or 3rd degree heart block?

Answer 222

Permanent transvenous pacemaker

Question 223

Why is anticholinergic overdose so deadly?

Answer 223

Any drug w/ anticholinergic effects (e.g. diphenhydramine) can cause multiple effects including tachycardia & seizures *In high doses, block Na channels --> lead to a prolonged QRS interval, prolonged QT interval, and lethal arrhythmias Anticholinergic s/e --> cutaneous vasodilation, anhidrosis, hyperthemia, mydriasis, delirium, hallucinations, urinary retention

Question 224

Acute mononucleosis from EBV - what 4 signs do you look for? What lab finding is key? What is tx? Most likely potential FATAL complication?

Answer 224

Tonsilar exudates Pharyngitis Cervical lymphadenopathy Fever Lymphocytosis w/ ATYPICAL lymphocytes Tx: symptomatic control --> acetaminophen/NSAIDs Deadly complication = Splenic rupture (no sports for at least 4 weeks)

Question 225

Pt w/ multiple myeloma has B/L leg weakness. Why is bone pain the first sign?

Answer 225

Osteoclastic bone lesions result from stimulation of osteoclasts & inhibition of osteoblasts by humoral factors elaborated by malignant plasma cells Multiple myeloma --> known to compress the spinal cord --> focal neurological deficits

Question 226

What is the caution in using metronidazole?

Answer 226

Avoid DRINKING!! Get a disulfiram-like reaction --> FLUSHING

Question 227

Nail pitting and distal destructive asymmetric arthritis w/ elevated ESR? What type of drugs to you need to avoid in this condition?

Answer 227

Psoriatic arthritis *Commonly nail bed deformities Sausage-shaped digits AVOID anti-malarials if disease-modifying therapy has started b/c they can exacerbate psoriasis

Question 228

Person younger than 45 yo w/ asymptomatic scant hematochezia (blood in stool) should receive what test? Why?

Answer 228

Anoscopy & flexible sigmoidoscopy Majority of lesions are in distal colon, rectum or anus

Question 229

First line for symptomatic bradycardia?

Answer 229

IV atropine

Question 230

What bug characterized by granulomatous-suppurative lesions that become widely disseminated in host is immunocompromised. Lesions may be seen in the brain. Stains weakly acid-fast but is bacteria?

Answer 230

Nocardia asteroides

Question 231

Symptoms & Signs of Cavernous Sinus Thrombosis? Diagnosis? Treatment?

Answer 231

HA, CN palsies, fever, diplopia, altered mental status *Proptosis, EOM impairment, *papilledema, ptosis, blurry vision Contrast CT / MRI scan Tx: parenteral Abx (adjuvant w/ LMWH & steroids)

Question 232

Why do you see pulsus paradoxus is severe asthmatics?

Answer 232

During severe asthma attack --> hyper-inflated lungs compress against the heart, decreasing heart's ability to fill with blood Needs intubation & mechanical ventilation

Question 233

What is mechanism of action of best initial treatment for Parkinson disease?

Answer 233

Levodopa MOA: dopamine precursor that CAN cross BBB where it's converted to dopamine - Combined w/ carbidopa, which blocks peripheral conversion of levodopa to dopamine

Question 234

Best initial test to evaluate suspected lung cancer that is centrally located? Best test to evaluate CT scan finding of a solitary lung mass?

Answer 234

Bronchoscopy w/ biopsy Bronchoscopy

Question 235

First line therapy for diabetic patients w/ HTN?

Answer 235

ACEi --> prevent progression of diabetic nephropathy

Question 236

Mgmt for post-chemotherapy neutropenia?

Answer 236

``` Afebrile = observation Febrile = Abx therapy ```

Question 237

Symptomatic mitral regurgitation from ischemic cardiomyopathy treatment?

Answer 237

Decrease Preload (loop diuretics) & Afterload (ACEi or B-blocker)

Question 238

33 yo with fever, chills, productive cough. Hx of past cellulitis and tricuspid valve endocarditis. Recent HIV test is pending. Has rhonchi in R mid-posterior lung field. CXR shows lobar consolidation w/ air-fluid level. What bug is responsible? What is best initial treatment?

Answer 238

S. aureus (see past hx of cellulitis & tricuspid valve endo) Very dangerous - necrotizing or cavitary pneumonia IV vancomycin or linezolid

Question 239

New-onset ascites in 50+ yo woman? What syndrome is this disease associated?

Answer 239

Ovarian malignancy w/ peritoneal metastasis Do pelvic ultrasound & paracentesis to determine SAAG (1.1 = transudative/portal HTN) *Meigs syndrome: ovarian tumor, ascites, pleural effusion

Question 240

2 causes of acute torticollis/dystonia? Tx?

Answer 240

Parkinson disease Drug s/e (antipsychotics) Tx: dopamine agonists, anti-ACh/H1, muscle relaxants, benzos

Question 241

Man w/ end stage renal failure found to have potassium level of 8.8. What is best initial therapy?

Answer 241

IV calcium gluconate - Works VERY rapidly to counteract the effect of high potassium on the heart and muscle by stabilizing cardiac membranes - Does NOT actually decrease level of potassium

Question 242

What 2 electrolyte abnormalities cause nephrogenic DI?

Answer 242

High calcium | Low potassium

Question 243

In pancreatic insufficiency, what vitamins will be deficient?

Answer 243

Vit A, D, E, K + Vit B12 *Need pancreatic enzymes to cleave B12 from R-binder (released in saliva) in order to have B12 bind to Intrinsic Factor!

Question 244

Side effect of hydralazine and test to confirm?

Answer 244

Drug-induced Lupus Anti-histone Ab

Question 245

What must you consider in a YOUNG person with a stroke or MI?

Answer 245

Polyarteritis Nodosa

Question 246

Most specific findings of multiple myeloma?

Answer 246

Increased monoclonal proteins (IgG, IgA) in urine/serum Clonal plasma cells from bone marrow biopsy Beta-2-microglobulin

Question 247

38 yo found to have at least 200 polyps on colonoscopy. What is most appropriate initial colon cancer screening strategy for his 2 children?

Answer 247

FAP --> autosomal dominant disease w/ mutations in APC gene 1st degree family members --> genetic testing for APC gene mutations If unavailable --> ANNUAL sigmoidoscopy/colonoscopy starting at 12 yo

Question 248

What are the 2 key findings in septic shock?

Answer 248

HIGH cardiac output LOW peripheral resistance Look for infection, peritoneal bacterial contamination (gut perforation)

Question 249

28 yo woman experiences episodes of passing reddish-brown urine in the morning after getting out of bed. The diagnosis can be confirmed by what finding?

Answer 249

*Flow cytometry showing deficient CD55 or CD59 on RBCs (anchor needed for cell membrane proteins to repel complement) PNH

Question 250

Characteristics of multi-infarct (vascular) dementia?

Answer 250

SUDDEN, STEP-WISE deterioration of mental function *Look for some improvement of symptoms followed by sudden deterioration of mental function after period of time Prominent gait, motor, or visual abnormalities MRI: cortical and subcortical infarctions and subcortical ischemic changes

Question 251

65 yo male has 3 yr history of progressive weakness. He has difficulty getting up from chairs, mild muscle cramps in his thighs, and difficulty swallowing. He has elevated CRP and CK. What is it? What is most accurate diagnostic test?

Answer 251

Inclusion body myositis Diagnostic test --> muscle biopsy

Question 252

Hallmark symptom of vertebrobasilar insufficiency (TIA)?

Answer 252

Dizziness/vertigo Other S/S: diplopia, dysphagia, dyarthria, facial numbness/paresthesia, syncope These TIAs much shorter than internal carotid TIAs

Question 253

Response of normal bone marrow to either infection OR trauma w/ exceedingly high WBC count (>50,000) and HIGH leukocyte alkaline phosphatase?

Answer 253

Leukemoid reaction

Question 254

Management of antiphospholipid syndrome?

Answer 254

Warfarin w/ INR b/w 2.0-3.0 FOR LIFE

Question 255

Man presents w/ vomiting bright red blood. No heartburn, dyspepsia, or EtOH consumption. No signs of cirrhosis, portal HTN. Nasogastric lavage returns bright red blood and endoscopy reveals blood in gastric lumen. No evidence of ulcers, gastric wall erosion, or esophageal/gastric varices. What is it?

Answer 255

First steps: 1) Nasogastric lavage 2) Volume resuscitation 3) Endoscopy * Dieulafoy's lesion --> dilated submucosal vessel that failed to branch into capillaries, penetrating overlying epithelium and bleeds. - Usually located along lesser curvature of stomach near GE junction

Question 256

This herb prolongs the INR in a patient on warfarin?

Answer 256

Dong quai

Question 257

Common findings in multiple myeloma?

Answer 257

- Pathologic fractures (doing everyday ordinary movements) - Elevated Calcium - Elevated total serum protein (hypergammaglobulins) - Anemia

Question 258

Person with Type1 DM and low B12, what must you investigate as cause of anemia?

Answer 258

Low serum B12 --> if low need to determine etiology: | - Pernicious anemia = dyspepsia, autoimmune conditions --> anti-IF & anti-parietal cell antibodies

Question 259

``` Dental extraction bleeding w/ petechiae and ecchymoses. Platelet count normal. PT & PTT normal. Bleeding time prolonged. Platelet aggregation studies showed: Ristocetin (normal) ADP (no response) Epi (no response) What is the cause? ```

Answer 259

Glanzmann thrombasthenia Deficient platelet glycoprotein IIb/IIIa complex Primary platelet aggregation response to platelet agonists (ADP, epi, collagen) are DECREASED but ristocetin response is normal.

Question 260

Ptosis & mitosis of a single eye in a person with long smoking history. What must you consider?

Answer 260

Pancoast tumor --> lung cancer in long time smoker at APEX (superior sulcus) of one lung - Compresses cervical sympathetic plexus - May also complain of scapular pain and radiculopathy in ULNAR distribution

Question 261

What physical exam findings are seen with traumatic diaphragmatic rupture?

Answer 261

L sided elevation of diaphragm --> abdominal viscera protrude into chest cavity on L side NG tube may also curl up into the chest Hemothorax may be only finding CXR shows bowel in L chest

Question 262

Treatment of herpes zoster (shingles) WITH neuropathic pain?

Answer 262

Acyclovir (famciclovir) + TCA (despiramine - neuropathic pain)

Question 263

What s/s suggest sarcoidosis? What is secreted by the granulomas? What lab finding is common?

Answer 263

Hilar lymphadenopathy NON-caseating (no necrosis) granulomas ACE produced 1,25-dihydroxycholecalciferol (ACTIVE Vit D) Hypercalcemia seen from increased Vit D

Question 264

Person with anemia (normal MCV) and no reticulocytes or erythroid precursors in the bone marrow. What organ must you investigate as cause? What condition has high incidence of co-existing?

Answer 264

Thymoma (thymus) --> PURE RBC APLASIA seen Myasthenia Gravis

Question 265

Signs of anticholinergic overdose?

Answer 265

``` Red as a beet = cutaneous vasodilation Dry as a bone = no sweating (anhidrosis) Hot as a hare = hyperthermia Blind as a bat = NONreactive mydriasis (dilated pupil) Mad as a hatter = delirium Full as a flask = urinary retention ```

Question 266

Type of lung cancer seen in nonsmokers, arises in periphery of the lung?

Answer 266

Adenocarcinoma

Question 267

What screening test should be done in men aged 65-75 who currently or have previously smoked?

Answer 267

Abdominal ultrasound (AAA)

Question 268

Patient is increasingly anxious and jittery. She is disoriented and easily distracted, however she dozes off when talking to you and has to be repeatedly awakened. Her complaints are abdominal pain and constipation. She has dry mucus membranes and orthostatic changes are present. What electrolyte abnormality do you suspect? What EKG changes would be present?

Answer 268

Hypercalcemia - Stuporous mental status changes - Intravascular volume depletion from osmotic diuresis - Constipation **Decreases renal sensitivity to ADH (nephrogenic DI) = osmotic diuresis **Hypercalcemia = BONES, STONES, GROANS, and PSYCHIATRIC OVERTONES EKG = QT segment shortening

Question 269

What are risk factors for stress gastric ulcers? How to differentiate between stress ulcer and ischemic colitis?

Answer 269

Risk factors: - Complicated hospital course - Prolonged intubation - Taking medications that cause coagulopathy (aspirin, heparin, warfarin) - Burns - Cranial trauma Look for upper GI bleed (black tarry stools) *DAYS after surgery (vs ischemic colitis where usual 1 day post-op) ALL patients should be given prophylactic H2 receptor or PPI

Question 270

Cholangiocarcinoma risk factors? Presentation and imaging findings?

Answer 270

Sclerosing cholangitis Recurrent pyogenic cholangitis (RPC) Chronic liver disease S/S: jaundice, itching, elevated LFTs & bilirubin Ultrasound: dilation of R & L hepatic biliary ducts (NO gallbladder or common bile duct involvement)

Question 271

AIDS patient with painful swallowing. What is initial treatment? What if symptoms persist?

Answer 271

Initial prophylactic Candida treatment CMV: deep large ulcers HSV: multiple small shallow ulcers

Question 272

S/S, imaging findings, and treatment of neurocysticercosis?

Answer 272

Caused by pork tapeworm (Taenia solium) S/S: SEIZURES, HA, increased intracranial pressure Imaging: cystic lesions and calcified lesions Tx: Albendazole

Question 273

What 2 serum markers are elevated in acute Hep B infection?

Answer 273

HbsAg (surface antigen) | anti-HBc IgM (core antigen)

Question 274

Complication of pancreatitis where person develops fever, chills, leukocytosis around 4 weeks after acute pancreatitis episode? What is treatment?

Answer 274

Infected pancreatic pseudocyst Percutaneous drainage *Look for fluid-filled cyst in pancreas off of pancreatic duct on CT

Question 275

What is classic story for corneal abrasion? What is initial treatment?

Answer 275

Foreign body sensation + painful, red eye Tx: topical anesthetic (tetracaine) to allow adequate physical, fundoscopy and fluorescein slit-lamp exam

Question 276

Person with abnormal behavior and confusion with abdominal pain resents with high calcium and low PTH. What are you thinking? What is next best test?

Answer 276

HYPERcalcemia --> bones, stones, groans, psychiatric overtones If calcium high and PTH is low --> think exogenous production of PTH-rp - Small cell carcinoma of lung Chest X-ray

Question 277

Most appropriate treatment for acute spinal cord injury

Answer 277

IV steroids after neurologic exam Brown-Sequard syndrome Compression from metastatic cancer (prostate, breast, lung)

Question 278

3 common causes of B12 deficiency? 8 signs of B12 deficiency? What is the name of severe B12 deficiency

Answer 278

Pernicious anemia Strict vegetarian Small bowel disease Pallor, Weakness, Paresthesia, Ataxic gait, Loss of vibratory sensation, increased DTRs, extensor plantar reflex, dementia *Subacute Combined Degeneration --> neurologic s/s of B12 deficiency

Question 279

Asymptomatic jaundice with conjugated hyperbilirubinemia w/o any LFT abnormalities. Also has elevated urine coproporphyrins. What 2 disorders could this be? How to differentiate the 2?

Answer 279

Dubin-Johnson syndrome OR Rotor syndrome Black liver = Dubin-Johnson syndrome

Question 280

Confirmatory test for MG?

Answer 280

EMG (progressive decrease in amplitude of muscle)

Question 281

Infections, inflammatory autoimmune disorders (RA), and cancers all can cause what blood disorder? What other blood test results are seen?

Answer 281

Anemia of chronic disease Microcytic anemia HIGH ferritin LOW TIBC LOW iron levels

Question 282

Treatment of recurrent calcium oxalate kidney stones?

Answer 282

Thiazide diuretics --> cause increased reabsorption of calcium from urine to decrease urinary calcium

Question 283

UTI treatment duration in men vs women? Tx of choice? Secondary option?

Answer 283

7 days for MEN; 3 days for WOMEN *DOC: quinolone TMP-SMX second-line

Question 284

Acute brain stem infarction (adult or child) best evaluated with what test?

Answer 284

Angiography of neck vessels --> determine sources of bleeding, thrombus, or stenosis.

Question 285

Differentiate between Gilbert syndrome, Criggler Najjar 1 & 2?

Answer 285

NO anemia with these! Gilbert: mild icterus from unconjugated hyperbilirubinemia *Triggered by certain events (fasting, physical exertion, illness, stress, fatigue) CN 1: severe jaundice and neurologic impairment due to kernicteris in infants - Indirect bili very high - Tx: phototherapy and plasmapheresis CN 2: lower serum bill levels and survival into adulthood with NO kernicteris/neuro impairment

Question 286

2 common side effects of isoniazid treatment?

Answer 286

``` B6 deficiency (replace w/ pyroxidine) INH hepatits (if mild, no worries) ```

Question 287

What types of nerve fibers are affected by Guillian Barre syndrome?

Answer 287

Demyelination of PERIPHERAL motor nerves (sensory and autonomic nerves also) *Ascending weakness w/ feet tingling

Question 288

Signs of pellagra? Deficiency of what?

Answer 288

Diarrhea (long term) Dementia (depressed mood, can't recall things) Dermatitis (sun-exposed areas w/ rash) Niacin

Question 289

Most common cause of loss of bile ducts in the liver in adults?

Answer 289

Primary biliary cirrhosis

Question 290

What are some side effects of celiac disease? What 2 antibodies are specific for celiac?

Answer 290

Diarrhea Fe deficiency anemia --> from malabsorption Rash = dermatitis herpetiformis anti-tissue transglutaminase IgA anti-endomysial IgA

Question 291

1st line tx for animal bites?

Answer 291

Amox-clavulanate

Question 292

Persistent rhinorrhea, congestion, asthma, and B/L nasal polyps all side effects of what drug?

Answer 292

Aspirin

Question 293

Management kg suspected scaphoid fracture?

Answer 293

Initial X-ray --> wrist immobilization for 6-10 weeks

Question 294

Person with MCV 75 and nucleated erythroblasts with red dots around the nuclei on peripheral smear. Also has fatigue and abdominal pain with headache. What is cause of anemia?

Answer 294

Lead poisoning * Sideroblasts: nucleated erythroblasts * Basophilic stippling: red dots (ribosomes) on periphery of erythrocytes *S/S: abd pain, neuro (HA, memory loss, foot drop)

Question 295

Explain SAAG? What is the cutoff value?

Answer 295

Serum-to-ascities albumin gradient > 1.1 = portal HTN (cirrhosis, cardiac, budd-chiari)

Question 296

Headaches, dizziness, pruritus (especially after showering), and splenomegaly are indicative of what hematologic disorder?

Answer 296

Polycythemia vera Look for increased RBC (Hb & Hct), WBC, and platelets HA and dizziness from increased blood viscosity

Question 297

What are the below parameters in septic shock: CO? PVR? PCWP?

Answer 297

CO: increased (due to extreme vasodilation - try to maintain BP) PVR: decreased (due to endotoxin causing vasodilation) PCWP: decreased (no preload do to third spacing of intravascular fluid)

Question 298

RBCs with single, round, blue inclusions on Wright stain. What are they? What do they indicate?

Answer 298

Howell-Jolly bodies (normally removed by the spleen) Indicate either physical absence of spleen or functional hyposplenism

Question 299

Person with alcoholic cirrhosis - what is the most import at screening test? If found, what is best prophylactic treatment?

Answer 299

Endoscopy - assess presence of varices If present and NON-bleeding = b-blocker

Question 300

What medications will exacerbate G6PD?

Answer 300

TMP-SMX Dapsone Primaquine

Question 301

In someone with hypertensive emergency, what is one of the best treatments? If given, what is a potential side effect? What are the signs?

Answer 301

Nitroprusside Cyanide toxicity Altered mental status, lactic acidosis, seizures, coma

Question 302

What are complications of Chagas disease?

Answer 302

Megacolon Megaesophagus Dilated cardiomyopathy

Question 303

What vitamin deficiency is seen with cracking of the corners of the lips, swollen tongue and mucus membranes, and red scaly patches on his eyebrows, cheeks, and nose. What is it?

Answer 303

Riboflavin (vit B2) deficiency

Question 304

Patient with dysphagia, coughing, halitosis, and a neck mass that varies in size with gurgling or swallowing foods/liquids. What is it? What is the cause behind it?

Answer 304

Zenkers diverticulum Esophageal sphincter dysfunction and esophageal dysmotility

Question 305

Effects of thyrotoxicosis are caused by what physiologic change?

Answer 305

T3 causing increased sensitivity to circulating catecholamines --> (+) chronotropic and inotropic effects --> myocardial contractility increases

Question 306

Thrombocytopenia (low platelets) are a finding in what chronic infection?

Answer 306

HIV

Question 307

Person with celiac sprue has normal Ca levels, low phosphate, elevated PTH and elevated Alk Phos. What is the cause?

Answer 307

Osteomalacia --> HIGH Alk Phos, low Ca, low Phos * Celiac sprue causes malabsorption of Vit D --> inadequate Ca and Phos reabsorption from the gut --> this triggers PTH release --> bone resorption increases Ca levels and Phos remains decreases * Secondary hyperparathyroidism

Question 308

Female with frequent headaches, fatigue and recent wt loss has should muscle stiffness in the mornings. A tender cord is palpated in the R temporal area. What is the most likely complication of this?

Answer 308

Giant cell (Temporal) Arteritis Association w/ Polymyalgia Rheumatica *Aortic Aneurysm

Question 309

2 week hx of weakness, low-grade fevers, and exertion dyspnea. Also has fingertip pain and his urine has been dark & cloudy recently. Several of his PIP and DIP joints are swollen. What is the cause?

Answer 309

Infective endocarditis Painful fingertips = Osler nodes Arthritis Glomerulonephritis Red non-tender lesions on palms and soles = Janeway lesions Red and bleeding lesions of retina = Roth spots

Question 310

Person has pain that is worsened after eating and leads to weight loss from no eating foods because of fear of the pain that will follow. What is the most likely cause?

Answer 310

Atherosclerosis of mesenteric arteries

Question 311

What describes a severe anemia with low or absent reticulocytes?

Answer 311

Aplastic crisis

Question 312

Most effective initial treatment for hypertension?

Answer 312

Lifestyle modification --> DASH diet, low Na intake, regular exercise

Question 313

Treatment for hepatic encephalopathy?

Answer 313

Lactulose --> helps draw ammonia out of blood into the gut

Question 314

Person with anemia, elevated BUN and creatinine, and high blood calcium - what is it? Next best test?

Answer 314

Multiple Myeloma (CRABBI) Serum immunoelectrophoresis --> M spike (IgG)

Question 315

How to differentiate between B-thalassemia trait and Fe deficiency anemia? what is seen on peripheral smear with B-thal?

Answer 315

B-thal trait: mild anemia, very high RBC count, Hgb > 10 Fe def anemia: LOW RBC count, microcytic when Hgb

Question 316

Person presents with shock from infection and has BP 70/40. Next day has LFT's in the thousands. Why?

Answer 316

Shock liver LFTs in thousands with slightly elevated total bilirubin and ALP

Question 317

Why is Graves disease at risk for developing HYPOthyroidism if treated with radioactive iodine?

Answer 317

In Graves, the ENTIRE gland is hyper-functional --> radio-iodine is taken up the the entire thyroid gland resulting in complete thyroid ablation

Question 318

What is the source of bleeding in Mallory-Weiss tear? What can help determine between artery or vein tear?

Answer 318

Ruptured submucosal ARTERIES of distal esophagus/proximal stomach *Prior upper endoscopy will show dilated veins if present (varices)

Question 319

What is a common side effect of dihydropyridine Ca-channel blockers (e.g. amlodipine)?

Answer 319

Peripheral edema --> these drugs cause dilation of peripheral blood vessels and leakage of fluid into interstitial space

Question 320

Person has periodic abdominal pain. Endoscopy shows multiple duodenal ulcers and a single jejunal ulcer. What is the cause of his impaired fat absorption? What is this?

Answer 320

Zollinger-Ellison syndrome *Jejunal ulcer pathognomonic Excess gastric acid produced --> inactivates pancreatic enzymes

Question 321

What 2 conditions present with difficulty swallowing solids and liquids, heartburn, and wt loss? Best initial test?

Answer 321

Achalasia and GE cancer Barium swallow --> shows dilation of upper esophagus with smooth narrowing of distal esophagus in ACHALASIA Before starting achalasia tx --> do endoscopy to r/o cancer

Question 322

What is the initial finding in Pancoast tumor? What are other s/s? Best initial test?

Answer 322

Shoulder pain *Horner syndrome (same side as shoulder pain) Ptosis, miosis, anhydrosis *Weakness/atrophy of hand muscles Get CXR

Question 323

Complication of prolonged immobilization (aside from rhabdo)? What is the mechanism and treatment?

Answer 323

Hypercalcemia Increased osteoclastic bone resorption --> starts occurring in week 4 after immobilization Bisphosphantes prevent bone loss

Question 324

77 yo male recently treated 3 months ago for pyelonephritis. Had cystoscopy done few days ago for persistent dysuria. Now he has new-onset heart murmur with painful red lesions on his fingertips. What bug is responsible for what he has?

Answer 324

Infective endocarditis **Recurrent UTIs and pyelo = ENTEROCOCCUS

Question 325

Difficulty hearing in a crowded or noisy environment - classic for what?

Answer 325

Presbycusis --> sensorineural hearing loss occurring with aging - Begins with symmetrical, high-frequency hearing impairment

Question 326

All patients with cirrhosis should have what screening test done?

Answer 326

Esophageal endoscopy --> r/o varices Also liver biopsy for hepatocellular carcinoma

Question 327

Man has attack of gout in R great toe. Also describes occasional headaches and pruritus that can be "unbearable" after a hot bath. What is the cause of his gout flares?

Answer 327

Polycythemia vera (myeloproliferative disorder) * Look for splenomegaly and pruritus after baths (histamine release from basophils) - Causes overproduction of purines from catabolism of cells

Question 328

Associated symptoms with chronic inflammatory diarrhea?

Answer 328

Anemia Elevated ESR Reactive thrombocytosis (increased platelets) *Positive stool blood test

Question 329

Most common cause of sepsis in sickle cell patients? | What is important prophylaxis?

Answer 329

S. pneumoniae Prophylaxis with Penicillin

Question 330

Patient has facial swelling upon waking up as well as b/l LE edema. 4+ proteinuria found as well as palpable kidneys and liver. S4 heard on auscultation. History of recurrent pulmonary infections from bronchiectasis and psoriasis. What is the cause of all this?

Answer 330

Secondary Amyloidosis (AA) *Nephrotic syndrome, palpable kidneys, hepatomegaly, ventricular hypertrophy (S4) w/ chronic inflammatory disease (recurrent pulm infections, bronchiectasis)

Question 331

Describe an acute hemolytic transfusion reaction?

Answer 331

* Develops WITHIN AN HOUR after blood transfusion has begun * Caused by ABO incompatibility * S/S: FLANK PAIN, fever, chills, hemoglobinuria May progress to DIC (+) Direct Coombs test

Question 332

How does cirrhosis affect transport protein levels of various hormones? Signs of cirrhosis?

Answer 332

DECREASES the transport proteins **TOTAL level of hormones are decreased, but FREE levels are unchanged (most bound to their plasma proteins) Jaundice, hepatosplenomegaly, ascites Telangectasias, Palmar erythema, testicular atrophy, gynecomastia

Question 333

What is the pathogenesis behind gynecomastia in cirrhosis?

Answer 333

Damaged liver can't metabolize circulating estrogen --> causes excess estrogen in bloodstream and causes: - Gynecomastia - Palmar erythema - Spider angiomas - Testicular atrophy & decreased body hair

Question 334

In a person with (+) HBeAg must be monitored with what tests?

Answer 334

*ALT (specific for hepatitis) HBeAg Every 3-6 months until they achieve viral clearance

Question 335

What are biliary cysts? What are the findings on exam?

Answer 335

Congenital/acquired dilations of the biliary tree 1) Abdominal pain 2) Jaundice 3) Palpable mass in RUQ

Question 336

In Sickle Cell disease, what is a common finding on peripheral smear?

Answer 336

*Howell-Jolly bodies (nuclear remnants of RBC normally removed by functional spleen) --> due to recurrent splenic damage and decreased function, can't remove these from RBCs

Question 337

What is Metoclopramide used to treat? MOA? Side effect?

Answer 337

Prokinetic agent used for nausea, vomiting, gastroparesis Dopamine receptor blocker (antagonist - like antipsychotics) **EPS --> dystonia

Question 338

What is Metoclopramide used to treat? MOA? Side effect?

Answer 338

Prokinetic agent used for nausea, vomiting, gastroparesis Dopamine receptor blocker (antagonist - like antipsychotics) **EPS --> dystonia

Question 339

Besides Barrett's, what is another complication of GERD?

Answer 339

Esophageal strictures --> progressive dysphasia to solids without wt loss Circumferential narrowing of distal esophagus

Question 340

Person has itching all over her body and when pooping takes forever to flush. Also has jaundice, enlarged liver and spleen. There is also elevated ALP, bilirubin, and (+) anti-mitochondrial antibodies. What is it and what other eye finding can be present?

Answer 340

Primary biliary cirrhosis (PBC) *Xanthelasma (eye cholesterol deposits) and xanthomas

Question 341

Person has itching all over her body and when pooping takes forever to flush. Also has jaundice, enlarged liver and spleen. There is also elevated ALP, bilirubin, and (+) anti-mitochondrial antibodies. What is it and what other eye finding can be present?

Answer 341

Primary biliary cirrhosis (PBC) *Xanthelasma (eye cholesterol deposits) and xanthomas

Question 342

How to distinguish Fe-def anemia from Thalassemia?

Answer 342

Thalassemia: NORMAL RDW, low RBC count **Peripheral smear: Target cells, Teardrop cells Fe-def anemia: HIGH RDW, low RBC count

Question 343

What electrolyte deficiency causes weakness, fatigue, muscle cramps in addition to broad flat T waves on EKG?

Answer 343

Low potassium

Question 344

Painless jaundice with elevated conjugated bilirubin is what until proven otherwise?

Answer 344

Pancreatic cancer or biliary tract cancer

Question 345

Person has TB and is taking isoniazid, rifampin, and pyrazinamide. He develops red urine. What is the cause?

Answer 345

Rifampin --> causes Red coloration of body fluids

Question 346

What is the test of choice to diagnose lactose intolerance?

Answer 346

Hydrogen breath test

Question 347

38 yo man has 6 mo history of persistent and progressively worsening knee and shoulder pain. He was recently diagnosed with diabetes. He has mild hepatomegaly on exam and knee joints are swollen and tender. LFTs are normal. Knee and shoulder X-rays show chondrocalcinosis. What do you suspect? Next best step?

Answer 347

Hemochromatosis **Pseudogout associated w/ hemochromatosis **Recent onset of diabetes Also can have hyper pigmentation, dilated cardiomyopathy Next best step --> serum iron studies (increased Fe and transferrin, ferritin)

Question 348

Person found to have MALT lymphoma without any evidence of metastasis. What is the association with this? What is treatment?

Answer 348

H. pylori associated with MALT lymphoma *If you treat the H. pylori --> the MALT lymphoma will usually resolve! Tx: PPI, clarithromycin, amoxicillin

Question 349

After a bout of pancreatitis, a person develops an epigastric mass that radiates pain to the back. Vitals are stable. Serum amylase is up to 308. What is the likely diagnosis? Tx?

Answer 349

Pseudocyst *Fibrous capsule containing inflammatory enzymes, including amylase, and when it ruptures it releases these into the bloodstream Tx: most resolve spontaneously

Question 350

What are signs suggestive of Zenker's diverticulum? What is a potential complication? Test of choice?

Answer 350

Dysphagia, REGURGITATION of food, HALITOSIS, occasional palpable neck mass *Aspiration pneumonia (R lower lobe) Test of choice: contrast esophagram (barium swallow)

Question 351

Man presents with unremitting nose bleeding. He had similar bleeding episodes in the past. He has several ruby-colored papillose on his lips that blanch partially with pressure. Digital clubbing is present. His Hct is elevated and platelet count is normal. What is causing his bleeding?

Answer 351

AVM in lungs --> shunt blood from R --> L heart in lungs without oxygenation --> causes chronic hypoxemia and a reactive polycythemia * *Osler-Weber-Rendu syndrome (hereditary telangiectasia) 1) Diffuse telangiectasias 2) Recurrent epistaxis 3) Widespread AV malformations

Question 352

What deficiency is manifested by hair loss, bullous and pustular lesions around the mouth and eyes, and a strange taste when eating foods? What other systemic diseases can precipitate this deficiency?

Answer 352

Zinc *Any malabsorption conditions (Crohns) --> zinc is absorbed in the jejunum

Question 353

What common findings are seen in people with anorexia?

Answer 353

**Osteoporosis (decreased estrogen from HPA abnormalities) Elevated cholesterol and carotene levels Prolonged QT interval (arrhythmias) Euthyroid sick syndrome HPA dysfunction --> anovulation, amenorrhea, estrogen deficiency Hyponatremia from excess water drinking

Question 354

Person in hospital is being treated for DVT. On the 6th day, they develop a cold R upper extremity with no pulse in that arm. The platelets have dropped significantly from admission and aPTT is elevated. What is the cause?

Answer 354

Heparin-induced thrombocytopenia --> from unfractionated heparin use **Elevated aPTT and thrombosis Antibodies to platelet factor 4 + heparin --> IgG binds to this complex --> causes platelet aggregation, thrombocytopenia, THROMBOSIS usually 5-10 days after staring heparin

Question 355

What physical manifestation is seen in malignant hypertension?

Answer 355

Papilledema

Question 356

What disease is characterized by recurrent oral ulcers, recurrent genital ulcers, anterior uveitis and skin lesions?

Answer 356

Behcet syndrome

Question 357

Common cause of B12 deficiency associated with autoimmune diseases such as thyroid disease and vitiligo, shiny tongue, and shuffling gait?

Answer 357

Pernicious anemia

Question 358

What signs are seen in Addison disease?

Answer 358

Adrenal failure **Hyperpigmentation Low BP Vitiligo Hyperkalemia

Question 359

Dark brown discoloration of the colon with lymph follicles shining through as pale patches - what is this?

Answer 359

Laxative abuse (melanosis coli) *Look for healthcare worker

Question 360

What condition is characterized by PAINLESS blisters (hands), increased skin fragility on the hands, facial hypertrichosis, and hyper pigmentation? What meds is it associated with? What medical condition is it associated with?

Answer 360

Porphyria cutanea tarda Ethanol, OCP --> trigger it Hep C

Question 361

What vitamin deficiency is commonly seen in alcoholics?

Answer 361

Folate!!

Question 362

What signs are seen with Vit D overdose?

Answer 362

Hypercalcemia --> abdominal pain, constipation, polydipsia, polyuria Vit D increases Ca gut absorption

Question 363

What condition can give you Marfan-like body habitus? How do you differentiate it from Marfans?

Answer 363

Homocystinuria * Fair skin & eyes * Intellectual disability * Thrombosis (stroke)

Question 364

Risk factors for osteoporosis?

Answer 364

Thin Smoking *Alcohol consumption (excessive) *Steroid use

Question 365

54 yo woman presents with dizziness and palpitations with exertion. Her feet feel "numb" and are less sensitive to cold. She has pale conjunctiva and a shiny tongue. Ankle reflex is decreased b/l. Labs show megaloblastic anemia. What is it? What should be monitored for long-term complications?

Answer 365

Pernicious anemia (Vit B12 def) * *Macrocytic anemia * *Glossitis (Shiny tongue) * *Neuro changes **Gastric cancer

Question 366

Person has fragmented RBCs on peripheral smear with low Hb. They also have low platelets and elevated BUN & creatinine. Headaches and confusion are present. PT is normal. What is it? What is treatment?

Answer 366

TTP 1) Hemolytic anemia 2) Low platelets 3) Renal failure 4) Neuro symptoms Deficincy in ADAMTS-13 (normally cleaves vWF units) or autoantibodies --> have large vWF multimers that cause platelet aggregation *Tx: Plasmapheresis (removes the autoantibodies)

Question 367

In a person with transient monocular vision loss (amaurosis fugax), what 3 conditions must you assume?

Answer 367

Emboli from carotid atherosclerosis (older people) Emboli from heart (AFib) Fibromuscular dysplasia (younger women)

Question 368

Anyone, even pregnant women, with a seizure and problems moving an arm?

Answer 368

Posterior shoulder dislocation

Question 369

27 yo female presents with very dark yellow urine and her boyfriend believes she is "more moody than usual." She has yellow sclera, spider nevi, rigidity, and tremor at rest. Slit-lamp shows greenish brown deposits around both corneas. Liver is enlarged with irregular edge. What is it?

Answer 369

Hepatolenticular degneration (Wilson disease) *Copper leaks from injured hepatocytes into the blood to be deposited in various tissues (basal ganglia/hepatolenticular and cornea)

Question 370

66 yo has 4 wk hx of increasing back pain and severe constipation. He has also been urinating excessively. He has no weakness or sensory loss. Only meds are Tylenol and metoprolol. Occult blood is (-). Hb is 9.5, BUN 28, Cr 1.9, and ESR is elevated. What is the cause for his constipation?

Answer 370

* Hypercalcemia * Causes polyuria, constipation, confusion, anorexia, weakness **Multiple myeloma --> remember CRABBI Back pain, anemia, renal dysfxn, elevated ESR ``` Calcium overload Renal failure Anemia Bone lytic lesions Infections (less Ig) ```

Question 371

Person has signs of intravascular hemolysis (low haptoglobin, low Hb, elevated bilirubin) and low platelets and WBCs. They have evidence of enlarged liver from hepatic vein thrombosis. What is the cause?

Answer 371

Paroxysmal nocturnal hemoglobinuria (PNH) **Increased risk of thrombosis (cerebral or abdominal) Flow cytometry for ABSENCE of CD55/CD59

Question 372

62 yo male has increasing fatigue and weakness for past 4 months. Has a dull pain in back and arms that is worse with walking, but no paresthesias or numbness. There is lumbar spine tenderness. His labs show normal WBC count, low Hb and Hct, and low/normal platelets. What must you consider? What would you see on peripheral smear? What would you see in urine? What about bone marrow exam?

Answer 372

Multiple myeloma Rouleux formation (stacked RBCs) Bence-Jones proteins (Ig light chains) Plasma cell over proliferation * *Hypercalcemia * *Lytic bone lesions (back pain) * *Recurrent infections * *Anemia * *Bence-Jones proteins in urine (light chains) * *Renal failure

Question 373

How does aspirin affect acid-base relationships?

Answer 373

Mixed acid-base disturbance Resp alkalosis --> aspirin (+) medullary resp center to INCREASE ventilation = decrease pCO2 Metabolic acidosis --> uncouples oxida phos and causes buildup of organic acids

Question 374

What is classic triad for splenic abscess? What other s/s can be present? What cardiac pathology is associated with this?

Answer 374

Fever, high WBC count, LUQ abd pain L-sided pleuritic chest pain, L pleural effusion, splenomegaly Infective endocarditis

Question 375

What medications are associated with increased risk of pancreatitis?

Answer 375

HCTZ, furosemide metronidazole, tetracycline valproic acid

Question 376

56 yo develops oliguria 3 days after having a kidney transplant. BP is 160/100 and his serum Na 145, K 5.5, Cr 3.2, BUN 30. Cyclosporine levels are normal. Biopsy of the transplant shows heavy lymphocyte infiltration and vascular involvement with swelling of the intima. What is the best treatment?

Answer 376

IV steroids *Oliguria, HTN, and increased Cr/BUN

Question 377

Most common cause of painless GI bleeding in elderly patients? What is a risk factor?

Answer 377

Diverticulosis Constipation

Question 378

Best treatment for hemodynamically stable pancreatitis?

Answer 378

IV fluids, analgesics, NPO

Question 379

What blood condition results in normocytic anemia, high reticulocyte count, and *high MCHC* with jaundice and splenomegaly? Test to confirm?

Answer 379

Hereditary spherocytosis Eosin-5-maleimide binding + acidified glycerol lysis test

Question 380

What vitamin deficiency is characterized by diarrhea, nausea, large tongue, hyper pigmented rash and poor concentration, irritability, or dementia?

Answer 380

Niacin deficiency

Question 381

Person with heparin-induced thrombocytopenia, what is the appropriate course of action?

Answer 381

Stop ALL heparin products | Switch to alternative agent (agatroban)

Question 382

What is the step-wise approach for treatment of ascites?

Answer 382

1) Fluid/Na restriction 2) Spironolactone 3) Loop diuretics (not more than 1L/day of diuresis) 4) Frequent abdominal paracentesis (2-4 L/day if renal fxn is ok)

Question 383

What other GI disease is associated with UC?

Answer 383

Primary sclerosing cholangitis

Question 384

Deficiency in hereditary angioedema?

Answer 384

C1 inhibitor deficiency

Question 385

Person on chemotherapy develops peaked T waves on EKG. Ca gluconate is given. What additional tx will help immediately lower his K?

Answer 385

Insulin + glucose --> drives K intracellularly

Question 386

Man has R-sided varicocele that does NOT empty when recumbent. What must you consider? What lab findings would be seen?

Answer 386

Renal cell carcinoma *Erythropoietin production Polycythemia --> increased Hb/Hct, platelets

Question 387

What triad of symptoms is multiple myeloma until proven otherwise?

Answer 387

``` Bone pain (back/chest pain) Renal failure (elevated BUN/Cr) Hypercalcemia ``` Also have anemia

Question 388

What disorder is characterized by bite cells and RBC inclusions? Inheritance pattern?

Answer 388

G6PD deficiency No G6PD = no creation of NADPH --> no glutathione which normally prevents oxidation of hemoglobin --> Hb denatures as it's oxidized into Heinz bodies *X-linked recessive

Question 389

Common findings in primary biliary cirrhosis? Lab finding diagnostic for PBC? Tx?

Answer 389

S/S: Pruritus, large liver, xanthomas (eye/skin/tendons), xanthelasmas * anti-mitochondrial antibodies * Tx: Ursodeoxycholic acid (slows disease progression and relieves symptoms)

Question 390

Man found to have elevated serum protein with normal albumin levels. Further workup showed monoclonal paraprotein band on serum protein electrophoresis. Several days later, repeat urine protein electrophoresis shows NO monoclonal protein. What is the best next step in mgmt?

Answer 390

MGUS --> NO anemia, hypercalcemia, or renal insufficiency

Question 391

18 yo African American man has 3 day hx worsening fatigue and exertional dyspnea. He had mononucleosis 2 weeks ago. Spleen is enlarged and mild scleral icterus is present. Labs show anemia with normal MCV and high reticulocytes. What else is likely to be seen on testing? What other conditions would have this same finding?

Answer 391

(+) Direct Coombs test --> COLD agglutinin AIHA *IgM present *CLL, EBV mononucleosis, SLE, Mycoplasma (walking pneumonia), penicillin

Question 392

In person with chronic kidney disease, what treatment is needed for anemia? What else must be given to also prevent anemia?

Answer 392

Erythropoietin --> stimulates progenitor cells in the bone marrow to create more RBCs --> surge in iron usage --> can cause rapid depletion in body's iron stores Supplement iron

Question 393

Person has chronic diarrhea and fecal fat content that is increased. D-xylose test shows decreased urinary excretion before and after Abx treatment. What is the cause?

Answer 393

Celiac disease --> D-xylose is monosaccharide that requires intact mucosa for absorption

Question 394

What is commonly found in the MIDDLE mediastinum? ANTERIOR mediastinum? POSTERIOR mediastinum?

Answer 394

MIDDLE --> bronchogenic cysts ANTERIOR --> thymoma POSTERIOR --> neurogenic tumors

Question 395

43 yo man with hx of allergic rhinitis and childhood eczema has chest pain with ST depression in lateral leads. Treated with aspirin, clopidogrel, LMWH, metoprolol, and lisinopril. On day 2 of hospitalization, has SOB w/ prolonged expiration and b/l wheezes. What is most likely cause of respiratory s/s?

Answer 395

Medication side effect from either aspirin or B-blocker * Aspirin --> causes bronchoconstriction (asthma) in people with chronic rhinitis and nasal polyps * B-blocker --> non-selective can trigger bronchoconstriction (B2 blockade)

Question 396

12 yo girl with L sided ear drainage that has persisted for 3 weeks despite antibiotics. She also has L sided hearing loss. There is peripheral granulation and some skin debris on otoscopic exam. What should be considered?

Answer 396

Cholesteatoma *Continued ear drainage for several weeks despite Abx therapy + hearing loss* Chronic middle ear disease leads to formation of retraction pocket in the TM which can fill with granulation tissue and skin debris.

Question 397

Most common cause of death in general population AND dialysis patients?

Answer 397

CV disease

Question 398

22 yo male develops resting tremor, muscular rigidity, and clumsy gait in addition to slurred speech. He has mild liver enlargement. He anemia and elevated LFTs. Liver biopsy shows inflammation and portal fibrosis with hepatocellular necrosis. What are you suspecting? How do you verify?

Answer 398

Wilson's disease --> liver, neuropsych (basal ganglia) *Ceruloplasmin (low) + slit-lamp for Kayser-Fleischer rings

Question 399

Person has episodic abdominal pain that wakes him at night and is relieved with glass of water and piece of bread. He experienced an occasional "dark stool." Vitals are stable. What is best option for long-term symptoms relief?

Answer 399

H. Pylori gastritis Antibiotics + omeprazole *(Amoxicillin + clarithromycin) + PPI

Question 400

Other extracolonic findings in UC?

Answer 400

* Erythema nodosum (painful, red nodules over extensor surfaces) * Pyoderma gangrenosum * Episcleritis * Arthritis --> similar to ankylosing spondylitis * Cholangitis --> elevated ALP * p-ANCA (+)

Question 401

What findings are classic in TTP?

Answer 401

Hemolytic anemia --> indirect hyperbilirubinemia, normocytic anemia, high reticulocytes Renal failure --> elevated BUN + Creatinine Low platelets Altered mental status

Question 402

Man has easy fatiguability for several months. He is a vegetarian and drinks alcohol daily. Hb is 10.8 and is given thiamine and folic acid daily. After several months, he reports recurrent falls and increasing forgetfulness. What is the most likely finding at this point?

Answer 402

Loss of proprioception in LE *B12 deficiency --> giving folic acid will correct the megaloblastosis but NOT the neurologic effects

Question 403

What should be suspected in any person with malabsorption and Fe-def anemia? Why will anti-tissue transglutaminase antibodies or anti-endomysial antibodies be absent in some cases?

Answer 403

Celiac disease * May be concurrent IgA deficiency --> these specific antibodies will be ABSENT * If the intestinal biopsy shows villous atrophy = celiac

Question 404

What feature is most characteristic of Crohn's vs UC?

Answer 404

Non-caseating granulomas in Crohn's

Question 405

Most common causes of folic acid deficiency? Medication-induced causes of folic acid deficiency?

Answer 405

Poor diet OR alcoholism Phenytoin (impaired absorption of folic acid) Methotrexate, TMP-SMX (both block folic acid physiologic effects - blocking dihydrofolate reductase)

Question 406

Why is hematuria the most common renal finding in sickle cell patients?

Answer 406

Isosthenuria --> sickling of RBCs block the vasa recta to renal papilla, causing impairment of countercurrent exchange mechanism in kidney --> painless hematuria

Question 407

What is common complication of upper endoscopy? How to verify?

Answer 407

Esophageal perforation *Water-soluble contrast esophagram --> does NOT irritate the pleura (contrast does)

Question 408

25 yo African male has nocturnia over past several months despite increasing fluid intake. Had recurrent OM as a child. Urinalysis shows no proteinuria or sediment abnormalities. What is the nocturnia from?

Answer 408

Sickle cell disease --> hyposthenuria (RBC sickling in the vasa rectae from the inner medulla --> impairs countercurrent exchange and free water absorption)

Question 409

47 yo man with several months of lethargy and decreased libido. Has OA and DM diagnosed 1 yr ago. Exam shows mild hepatomegaly and testicular atrophy. What cardiac abnormality is most likely to be present?

Answer 409

Hemochromatosis Conduction abnormalities, restrictive/dilated CM * Hypogonadism (testicular atrophy, decreased sexual drive) * Arthopathy * Diabetes * Hepatomegaly Look for: * Hepatic fibrosis/cirrhosis * DM * Arthopathy (pseudogout) * Skin pigmentation * ED

Question 410

Best tx for sickle cell disease in the acute setting?

Answer 410

Exchange transfusion (decrease % of sickled cells in circulation)

Question 411

Best step in hypothermia?

Answer 411

Active rewarming

Question 412

What treatment is given to people who do NOT want elective cholecystectomy?

Answer 412

Ursodeoxycholic acid --> decreases cholesterol content of bile by reducing hepatic secretion and intestinal reabsorption of cholesterol

Question 413

25 yo female comes for preconception counseling. Her grandparents are from Greece and her husband's family is Mediterranean descent. Her mother and sister have been diagnosed with anemia. Thalassemia anemia is suspected. What is the most appropriate initial screening test?

Answer 413

CBC --> determine hemoglobin concentration | *If anemia is present + reduced MCV = further testing

Question 414

Mechanism behind hemophilia causing joint damage?

Answer 414

Iron/hemosiderin deposition in joint space leading to synovitis and fibrosis within the joint

Question 415

Why would a person with RA receiving treatment have a macrocytic anemia?

Answer 415

Methotrexate --> folate antimetabolite (blocks utilization of folate in cells)

Question 416

Metformin should NEVER be given in what situations?

Answer 416

Acute renal failure, liver failure, sepsis --> risk of lactic acidosis

Question 417

C. difficile, aside from Abx, is associated with what other medications?

Answer 417

PPI or H2 blockers