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COMAT Exams > Internal Medicine > Flashcards

Internal Medicine Flashcards

1
Q

Identify type of vitamin deficiency?
13 year old male recently emigrated from china after being diagnosed with congestive cardiomyopathy

name of dz?
what other areas have this problem?
what are foods rich in this vitamin?

A

Selenium deficiency = KESHAN dz

  • -congestive cardiomyopathy, enlarged heart
  • -China, New Zealand, Finland
  • -selenium rich foods = fish, shellfish, eggs
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2
Q

Identify type of vitamin deficiency?
Immigrant from middle east with stunted growth and hypopigmented hair, frequent infections, decreased taste sensation

what are other presenting symptoms?

A

Chronic deficiency

  • -middle eastern countries
  • -foods rich in zinc = oysters, beef, crabs, cereal
  • -night blindness, decreased spermatogenesis
  • -severe deficiency = diarrhea, alopecia, pustular dermatitis, decreased immunity
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3
Q

Identify type of vitamin deficiency:
54 year old presents with sensory and motor impairments, mostly of distal extremities

what is the most common cause?
what are two presenting forms?

A

Vitamin B1 - Thiamine
–most common cause of deficiency = alcoholism

Wernicke-Korsakoff syndrome - horizontal nystagmus, ophthalmoplegia, cerebellar ataxia, mental impairment, confabulation psychosis

Beriberi

  • Dry = symmetrical peripheral neuropathy (motor + sensory)
  • Wet = neuropathy + CHF (cardiomegaly, lower extremity swelling, tachycardia)
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4
Q

identify type of vitamin deficiency:
45 year old male from Africa with hyperpigmented scaling rash on the sun exposed area of his neck.

what is the name of this?

A

Niacin (B3) deficiency

  • -Casal’s necklace
  • -3D’s (diarrhea, dermatitis, dementia)
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5
Q

identify type of vitamin deficiency:
67 year old male w two day history of paresthesias and witnessed SEIZURES

what are additional symptoms?

A

Calcium deficiency

-paresthesias, peri-oral numbness, seizures, muscle cramps/spasms

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6
Q

What is the diagnosis?
46 year old HIV positive male w SOB and profuse epistaxis. Bloody diarrhea and left flank pain. Diffuse petechial rash, non-focal neuro exam, tissue texture changes from T9-T11 bilaterally.
Anemia, thrombocytopenia, acute renal failure, schistocytes in peripheral smear

what study can confirm dx?

A

Hemolytic uremic syndrome

stool culture fro E. coli O156:H7

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7
Q

What is dx:
51 year old w diffusely erythematous skin rash w associated fever. pt takea tenolol and allopurinol for HTN and gout. Rash is tender and over over 90% of body. Lymphadenopathy noted in the neck and inguinal region. elevated eosinophils, AST, ALT

what are some causes

A 
DRESS syndrome (Drug reaction w eosinophilia and systemic symptoms)
-extensive rash, fever, lymphadenopathy, hematologic abnormalities, hepatitis, involvement of atleast one internal organ

meds that cause DRESS:
allopurinol
anticonvulsants, sulfa derivatives, antidepressants, NSAIDs, antimicrobials

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8
Q

What follow up actions should be taken to assess End organ damage from HTN?

A
  1. fundoscopic exam
  2. auscultation of major arteries for bruits
  3. Palpation of organs for enlargment
  4. check for lower extremity edema
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9
Q

What is the most common cause of secondary HTN?

A

Renal dz

in young pts - think fibromuscular dysplasia

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10
Q

What is the usual intial treatment for SIADH if the pt does not have severe neurological Sx?

what if the pt has severe neuro sx?

A

No Neuro Sx: Water restriction

Severe Neuro Sx: rapid partial correction of sodium (HYPERTONIC Saline)

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11
Q

What are some criteria that suggest a dx of SIADH?

A

SIADH is a dx of exclusion

  1. Euvolemic
  2. Urine is not maximally dilute (150-200mmol/L)
  3. Urine sodium > 20mmol/L
  4. normal adrenal and thyroid function
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12
Q

What is the strategy of choice for cardiogenic shock

A

Emergency PCI

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13
Q

what is dx?

acute chest pain with free air under diaphragm on CXR

A

Perforated peptic ulcer

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14
Q

A 65 asymptomatic male presents for a routine wellness examination. Hx of HTN, 30 pack year smoking hx. active lifestyle. Cardiac/lung exam are unremarkable

what is the most appropriate prevention recommendation at this time?

A

Abdominal ultrasound

–Abd US screening for Abdominal aortic aneurysm for all men aged 65-75 who have ever smoked in their lives

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15
Q

What is the type of arrhythmia?
57 year old male is brought to the ED unconscious after a witnessed episode of syncope. ECG shows wandering baseline and irregular complexes w faint pulse

A

Ventricular fibrillation

Afib has a irregular palpable pulse

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16
Q

what is the type of arrhythmia?
68 yr old female w hx of diabetes and HTN presents to the ED w weakness in the R leg. ECG shows a supraventricular tachyarrhythmia w an atrial rate of 425/min

A

Atrial fibrillation

–atrial rate is > 400/min

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17
Q

what is the type of arrhythmia?
40 year old female w phm of rheumatic heart disease presents w fatigue and dyspnea. ECG shows narrow complexes at 150/min in a regular rhythm w F waves in leads II, III, and aVF

A

Atrial flutter

F waves = sawtooth pattern, best seen in II, III, aVF

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18
Q

what are the drugs of choice for congestive heart failure

A

ACE inhibitors

B-blockers

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19
Q

What its the initial therapy for Immune thrombocytopenic purpura?

what should to performed if pts do not respond to medication chronically?

A

Oral Corticosteroids

–Splenectomy if pt doesnt respond to medication chronically

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20
Q

Describe the 5 parts of Thrombotic Thrombocytopenic Purpura syndrome

What is the cause of TTP?

A
  1. microangiopathic hemolytic anemia
  2. thrombocytopenia
  3. neurologic abnormalities
  4. fever
  5. renal dysfunction

Cause = ADAMTS13 deficiency = excess vWF = microvascular thrombi

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21
Q

Describe Hemolytic Uremic Syndrome

A

clinical complex consisting of

  1. progressive renal failure
  2. microangiopathic hemolytic anemia
  3. thrombocytopenia
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22
Q

Identify the syndrome and cause of thrombocytopenia:
Pt treated for Rheumatoid arthritis with chronic steroids. Fullness of upper left abdomen. Low platelets, neutropenia, anemia.

A

Felty Syndrome:

  1. rheumatoid arthritis
  2. neutropenia
  3. splenomegaly
  4. lymphadenopathy
  5. thrombocytopenia

Splenomegaly causes sequestration of platelets = thrombocytopenia

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23
Q 
What is the:
MCV
Ferritin
TIBC
RDW
in a 34 year old man of mediterranean descent with a fam hx of anemia
A

MCV - Decreased
Ferritin - Increased
TIBC - Normal
RDW - Normal

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24
Q

what is the best intervention to slow the progression of Diabetic Nephropathy?

A

Angiotensin inhibition

  • -ACE-i
  • -ARB
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25
Q

what is the classic triad of acute cardiac tamponade

A

Beck’s Triad:

  1. Hypotension
  2. elevated Jugular Venous Pressure
  3. Small quiet heart

**Look for Pulsus Paradoxus (decrease of >10mmHg systolic w inspiration)

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26
Q

What was the most common cause of constrictive pericarditis in the US in the past?

what is the most common cause presently?

A

Tuberculosis

present: Radiation therapy, surgery, viral infection, uremia, malignancy

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27
Q

What cardiac condition is related to a pattern of alternating amplitude of QRS complexes

A

Electrical Alternans - Cardiac tamponade

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28
Q

What is the appropriate next step after suspecting pleural effusion from history and chest xray?

A

Diagnostic thoracocentesis - diagnose cause of the pleural effusion and determine the necessity for fluid drainage

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29
Q

What is the immediate support care for a patient with cardiac tamponade awaiting pericardiocentesis?

A

Intravenous fluids - pts with cardiac tamponade are preload dependent, fluids help maintain intravascular volume and cardiac output

–diuretics, nitrates, morphine may cause pts to become hypotensive

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30
Q

How do you interpret hematocrit levels of pleural fluid?

A

Hemothorax (trauma, malignancy) = pleural fluid HCT is >50% of Hct of peripheral blood

Cancer, PE, Tuberculosis (pleural Hct <50% Hct of peripheral blood)

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31
Q

What is the criteria to determine the difference between transudative and exudative fluid?

A

Light Criteria

  • -EXUDATES meet at least one of the following criteria:
    1. Pleural fluid protein/serum protein ratio >0.5
    2. Pleural fluid LDH/serum LDH ratio >0.6
    3. Pleural fluid LDH >2/3 the upper limit of normal for serum LDH
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32
Q

What fluid characteristics suggest the need for chest tube drainage? (6)

A
  1. Empyema (frank pus in the pleural space)
  2. Positive Gram stain or culture of fluid
  3. Presence of loculations
  4. pH less than 7.20 (normal pleural - 7.6)
  5. Glucose less than 60 mg/dL
  6. LDH more than 1000 U/L
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33
Q

What is most appropriate next step when suspecting pulmonary edema?

A

Chest CT with intravenous contrast or other imaging study as indicated.

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34
Q

What is the most useful nonimaging diagnostic test for a PE?

A

D-dimer ELISA

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35
Q

What are ECG findings that suggest a PE?

A

usually: Sinus Tachycardia
rarely:
S1Q3T3 (inverted T wave in lead III)

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36
Q

What is the sequence of diagnostic tests used for diagnosing PE?

A
  1. Chest CT
  2. Lung Scan (V/Q)
  3. Venous ultrasound to look for DVT
  4. Transesophageal Echo
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37
Q

What is the best treatment for a DVT in a patient that presents with significant vaginal bleeding from cervical cancer?

A

vaginal bleeding = contraindication for anticoagulation

use Vena Cava filter

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38
Q

What is a side effect of biologic DMARDs TNF antagonists (etanercept, infliximab, adalimumab)

what should you do before prescribing?

A

increase risk of infection (reactivation of latent TB)

–pts should be screened for TB

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39
Q

Identify cause:
72 year old man w severe pain and swelling in knees post surgery. Intracellular and extracellular weakly positive birefringent crystals in synovial crystals

A

Pseudogout

gout - NEGATIVELY birefringent crystals

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40
Q

What would synovial fluid show in a patient with Gonococcal arthritis?

A

elevated (>72,000) WBC’s

>75% Polymorphonuclear leukocytes

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41
Q

What location in the lung does:
1. primary pulmonary TB
2. reactivation TB
affect?

A
  1. often in children - Middle and lower lobes

2. Apical and posterior segments of upper lobes

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42
Q

What disease is characterized by
asymptomatic or dysuria, hematuria, urinary frequency
+ the finding of leukocytes in the urine but negative bacterial cultures?

A

“Sterile pyuria” = Genitourinary TB

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43
Q

What are the tuberculin reaction sizes and the related circumstance required for diagnosis of latent M tuberculosis infection

A
  1. > 5mm - HIV, close contact w TB pt, Fibrotic lesions on CXR
  2. > 10mm - Recently infected (<2y), high risk medical conditions
  3. > 15mm - low risk persons
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44
Q

What supplementation is often used along side Isoniazid?

A

Pyridoxine - prevent peripheral neuropathy

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45
Q

How is a latent TB infection treated?

A

Isoniazide for 9 months

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46
Q

Which testis the most important to follow for a patient receiving isoniazid and rifampin for TB treatment?

A

Liver function tests

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47
Q

What is the criteria for the diagnosis of at UTI in the elderly?

  1. clean catch
  2. specimen from catheterization
A
  1. 10^5 colony-forming units

2. 10^2 colony-forming units

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48
Q

How does distributive shock differ from cardiogenic and hypovolemic shock?

A

distributive - often caused by sepsis

  • –increase in cardiac output
  • –inability to maintain systemic vascular resistance (inappropriate vasodilation)
  • –***EXTREMITIES ARE WARM AND WELL PERFUSED = “Warm phase”

can progress to “Cold phase” - intense vasoconstriction in an apptempt to maintain blood pressure - bad prognosis b/c sepsis should be caught during “Warm phase”

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49
Q

What is the intial management of an acute arterial occlusion?

A

Anticoagulation w heparin to prevent propagation of the thrombus

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50
Q

What the next best diagnostic step when COPD is suspected? what is the best initial treatment?

A

dx: ABG to assess oxygenation and acid-base status
tx: oxygen by nasal cannula,, bronchodilators and steroids for airway inflammation

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51
Q

What is the usual diagnostic criteria for COPD?

A

FEV1/FVC <70%

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52
Q

What therapy provides the greatest benefit to a patient with chronic stable emphysema and a resting oxygen sat of 86%

A

Supplemental oxygen used continuously
smoking cessation
–only medical therapies shown to decrease mortality among COPD pts

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53
Q

What type of movements are still present in a patient that is brain dead?

A 
Spinal reflexes (outside the brainstem)
ex: facial nerve twitching, fasiculations of trunk/extremities
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54
Q

What is contraindicated in an unconscious patient that drank drain-O?

A

NPO - do not intubate - may exacerbate the damaged mucosa from the drain-O = can cause esophageal rupture

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55
Q

When should valve replacement be considered in a patient with aortic stenosis?

A

aortic valve with an area less than 1 cm2

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56
Q

The monitoring of which electrolyte is important in congestive heart failure?

A

Sodium - reduce sodium intake to control fluid retention

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57
Q

What is the therapy of choice for acute Otitis Media? when is observation appropriate?

A

High dose oral Amoxicillin

-Pts > 2 yrs w recent onset of non-severe illness are observed to prevent the misuse of antibiotics when OM is caused by viral pathogen

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58
Q

When should tPA or surgical embolectomy be used as primary therapy for a PE?

A

When the pt is at high risk if the embolism stays
it pt has:
1. Right heart failure
2. Hypotension (systolic >90mmHg)

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59
Q

What is the preferred daily medication for a patient with a history of asthma and nocturnal awakenings secondary to cough and occasional wheezing that occurs 3-4 times per week?

what is the classification?

A 
Moderate persistent (daily symptoms, nocturnal awakenings >1/week)
--long acting B2-agonist = preferred therapy
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60
Q

What is the preferred daily medication for a patient with a history of asthma where symptoms occur >2/week, < 1/day, >2/month nocturnal symptoms?

what is the classification?

A

Mild persistent asthma (>2/wk;<1/day symptoms, >2/month nocturnal awakening)

–Low-dose inhaled steroids = preferred therapy

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61
Q

What type of lung cancer is most likely to appear as a CAVITARY LESION on CXR? what are the associated paraneoplastic syndromes?

where in the lung is it usually located?

A

Squamous Cell Cancer

  • -produced PTH-like hormone
  • ——causes hypercalcemia

typically CENTRAL/HILAR

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62
Q

What are extrapulmonary manifestations of Small Cell Lung Cancer?

A

SIADH
ectopic ACTH - Cushing
Eaton-Lambert
-peripheral neuropathy

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63
Q

What do most patients presenting with hemoptysis require?

A

bronchoscopy

—massive hemoptysis may result in death from asphyxiation

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64
Q

What is the management of a solitary pulmonary nodule in relation to size?

A

nodules <8mm = follow radiographically

nodules >8mm = biopsy, consider surgical resection

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65
Q

what is the use of aztreonam?

A

used with patients with penicillin allergy for gram negative rod infections (ie pseudomonas)

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66
Q

What therapy should be administered in a patient with dry/cracked skin cellulitis? (what is the most likely pathogen)

A

most likely pathogen = Streptococci / Staphylococci

Nafcillin = first line therapy

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67
Q

How is FeNa calculated? how do you interpret results?

A

FeNa = 100x(Serum creatinine/Urine creatinine)/(Serum Sodium/Urine Sodium)

<1% = prerenal azotemia (ie volume depletion)
>2% = ATN, AIN
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68
Q

How is the BUN/serum CR ratio interpreted?

A

BUN/Cr >20:1 = pre-renal disease (ie volume depletion, renal A stenosis)

BUN/CR = normal or 10 to 15: 1 = ATN, AIN

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69
Q

How is urine Sodium interpreted in regards to kidney injury?

A

Urine sodium < 20 mmol/L = pre-renal azotemia

Urine sodium > 40 mmol/L = ATN, AIN

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70
Q

What is the pharmacologic management of acute symptomatic hypocalcemia?

A

IV 10% Calcium gluconate

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71
Q

A pt treated for hypocalcemia with IV Calcium gluconate still shows hypocalcemia. What other electrolyte infusion should have been administered first?

A

Magnesium

–hypomagnesemia can cause PTH resistance

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72
Q

What criteria index used to risk-stratify pneumonia patients?

A

CURB-65

  1. Confusion
  2. Urea >20 mg/dL
  3. Respiratory rate > 30bpm
  4. Blood pressure, systolic <90mmHg
  5. Age > 65

score >2, pt should admitted to Hospital

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73
Q

What is the typical outpatient therapy of community acquired pneumonia?

A

Macrolide Abx = Azithromycin, doxycycline, antipneumococcal quinolones (moxifloxacin, levofloxacin)

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74
Q

Which atypical organism is most likely responsible?
65 year old smoker w hx of HTN, mild CHF, presents with worsening cough, fever, muscle aches, abdominal pain, diarrhea, non productive cough developing later that week and rapidly becoming worse.

A

Legionella pneumophila - typically presents w:

  1. myalgias
  2. abdominal pain
  3. diarhea
  4. severe pneumonia
    * consider because of history of smoking
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75
Q

What is the most appropriate initial Abx choice:
85 year old nursing home resident w hx of CHF, dementia. Presents w 3 day hx of fever, productive cough, CXR shows right middle lobe consolidation

A

IV cefepime:
—nursing home = pneumonia is nosocomial not CAP
=high incidence of gram negative
—age, med hx = high risk = hosptialization and IV cephalosporin

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76
Q

What is the most appropriate management of aspiration pneumonitis?

A

Supportive care = observation w follow up CXR

77
Q

what is the statistical advantage of a D-dimer? what does this mean?

A

very high negative predictive value

  • can have false positives
  • if ddimer is negative no further testing for PE
78
Q

What is the lab test to check for the following causes of hepatitis:

  1. Wilson disease
  2. Hemochromatosis
A
  1. Low serum ceruloplasmin

2. High transferrin saturation (>45%), high ferritin

79
Q

45 year old admitted for acute pancreatis. after 3 months he still has epigastric but is able to eat solid food. amylase level is elevated at 260 IU/L

what is dx?

A

Pancreatic pseudocyst - presents as:

  1. abdominal pain/mass
  2. persistent hyperamylasemia
80
Q

what is the pharm therapy for chronic hep B infection

A

interferon and oral Lamivudine

81
Q

How does essential tremor usually present?

A

bilateral hand tremor (frequency 4 to 6 Hz) that exacerbates with actions

improvement: beta blockers, anticonvulsants, small amounts of alcohol

82
Q

What is the most common electrolyte abnormality in diabetic ketoacidosis?

A

hyperosmolar HYPONATREMIA

–from the plasma dilutional effect of hyperglycemia

83
Q

A patient with DKA dies secondary to a cardiac arrest. correction of what electrolyte abnormality could have prevented this patients death?

A

Potassium - DKA causes massive potassium loss

  • -correction of DK Acidosis with insulin causes potassium export from cells into intracellular space
  • –correction of acidosis causes renal loss of potassium = cardiac arrhythmias, arrest
84
Q

What use is Zoledronic acid reserved for?

A

zoledronic acid = IV bisphosphonate

–used for prevention of skeletal fractures in patients with Multiple Myeloma and Prostate Cancer

85
Q

The feeding of a patient (alcoholic, anorexic, malnourished) causing generalized tremors of entire body with confusion.

what is the cause?

A

Refeeding Syndrome - insulin causes uptake of phosphate by cells
–compensatory respiratory alkalosis = further intracellular shift of phosphate

HYPOPHOSPHATEMIA = myopathy, rhabdomyolysis, respiratory failure and severe CNS system dysfxn.

86
Q

What does a more than 20:1 BUN:Cr ratio indicate about the type of kidney injury?

A

Prerenal failure

87
Q

What is the next diagnostic step when Acute Kidney Injury is suspected from a high BUN:Cr level?

A

Urinalysis and urine chemistries to determine whether the process is prerenal or renal or postrenal (less likely)

88
Q

What are the urinalysis findings of:

  1. prerenal failure
  2. postrenal failure (what microscopic findings for which types of obstruction)
A
  1. high specific gravity and normal microscopic findings
  2. urine osmolality is equal to the serum osmolality,
    microscopic findings:
    —Hematuria = crystals or stones
    —leukocytes = prostatic hypertrophy
    —normal = extrinsic ureteral compression
89
Q

What are urinalysis findings of Ischemic and Nephrotoxic ATN?

A
  1. Isothenuric (urine osmolality is equal to serum osmolality)
  2. proteinuria - containing muddy brown granular casts
90
Q

What is the treatment of hyperkalemia?

A

C BIG K

-Calcium, Bicarb/B-agonis, Insulin, Glucose, Kayexalate

91
Q

What is the first line therapy for treating Osteoarthritis?

A

NSAIDs - NOT Acetominophen

92
Q

What is the most probably diagnosis:
82 yr old female with sudden onset right knee pain. PMH of DM type 1, alcohol abuse, total right knee arthroplasty 6 months ago. Phys exam shows hot, red, swollen knee, with limited range of motion.

A

Septic Arthritis -
sexually active young adult - N. gonorrhea
everyone else - S. aureus

sudden onset joint pain, warm, erythematous, tender joint, limited range of motion.

93
Q

Monoarthritis with sudden onset pain and swelling. Intra-articular fluid aspiration shows 10,000 leukocytes and negatively birefringent (yellow in parallel light) needle shaped crystals

what is dx and risk factors?

A

Gout

–male gender, diuretic use, alcohol abuse

94
Q

acute onset knee pain, rhomboid shaped crystals, positively birefringent

A

Pseudogout - positively birefringent (blue in parallel light)

95
Q

What is the dx:
4 year old African American child w fever, pallor, fatigue, back pain. Pallor of conjunctiva, rales at right lung base, petechiae diffusely over the body. Labs show high white blood cell count and anemia

A

Acute lymphoblastic leukemia

96
Q

How do you interpret the T-score of a DEXA scan?

A 
Normal = Tscore > -1 Standard Deviation
Osteopenia = T-score of -1 to 2.5 SD
Osteoporosis = T-score less than 2.5 Standard dev
97
Q

What is the most likely diagnosis:
28 year old woman from Nigerial w 6 month history of persistent lower lumbar back pain, a/w low-grade fever, and night sweats. point tenderness over spinous processes of L4-L5

A

Tuberculous osteomyelitis (Pott disease)

98
Q

What is the next best step in management:

45 year old man w saddle anesthesia and decreased ankle reflexes bilaterally?

A

Cauda equina syndrome - immediate referral for advandced imaging and surgical evaluation for decompression to avoid long-term denervation

99
Q

What kind of kidney stone can be prevented with the acidification of urine (ie drinking cranberry juice)

A

Calcium Phosphate stones (form in alkaline urine)

100
Q

right lower lobe nodule is found incidentally on CXR. follow up CT shows nodule to be 7mm with popcorn like calcification

what is dx?

A

Pulmonary Hamartoma - do not have malignant potential

-composed of tissue elements normally found at site.

101
Q

What is the highest risk factor for cervical cancer?

A

Multiple sex partners - contracting HPV 16, 18, 45, 33, 58

102
Q

how do you differentiate arthritis from soft tissue disorders (ie cellulitis, or bursitis)?

A

True arthritis = swelling, redness, painful limitation of motion in all planes during ACTIVE AND PASSIVE motion.

soft tissue disorder - joint movement is not limited by passive motion

103
Q

What are the leukocyte levels in synovial fluid for:

  1. Inflammatory
  2. Septic?
A
  1. leukocytes: 2000-75000

2. leukocytes: >100,000

104
Q

In the case of inflammatory arthritis what does Chondrocalcinosis or linear calcium deposition in joint cartilage suggest?

A

Pseudogout

105
Q

What preventative medication should be used in a patient with gouty arthritis and renal disease?

A

Febuxostat (Allopurinol needs to be given in lower doses in patients with renal insufficiency)

106
Q

What diagnostic test should be used to dx a gonococcal cause of arthritis?

A

gonococcal infection findings in urethra, cervix, pharynx

  • -synovial fluid cultures are usually sterile in gonococcal arthritis
  • -blood cultures are positive less than 50% of the time.
107
Q

What is the most ideal site for a creation of an AV fistula for dialysis?

A

Radial artery

Cephalic vein

108
Q

What are abnormal Orthostatic vital signs?

A

Drop of:
20mmHg Systolic
10mmHg Diastolic

upon standing

109
Q

What is the most appropriate diagnostic modality for a patient with a Syncopal event and normal physical exam?

A

24-hour Holter monitor

110
Q

What are the characteristics of Coma?

A

Complete failure of arousal system
Reflexes, postural responses are intact
EEG shows auditory brainstem response

111
Q

25 year old male with 20% total body surface burns to legs and chest. Rapid sequence intubation in successfully performed for airway protection. He later dies of from cardiac arrest. What happened?

A

Hyperkalemia - from Succinylcholine administration in burn patient

112
Q

What is the dx:
35 year old female w vertigo, nausea, vomiting. Constant ringing in ear and hx of recent flu-like illness.
Mild hearing loss, positive Dix-Hallpike maneuver

What is the appropriate management?

A

Labyrinthitis - inflammation of labyrinth of inner ear. most often seen after viral upper respiratory tract infection.

*both labyrinthitis and BPPV have a positive Dix-Hallpike maneuver

Tx: Meclizine (antihistamine), Prochlorperazine (antiemetic)

113
Q

What is the next step when a Transient ischemic attack is suspected?

what medication should be administered? in what time frame?

A

NONCONTRAST CT of the brain.

thrombolytics (IV recombinant tPA) - within 3-4.5 hours

114
Q

When should carotid endarterectomy be performed?

A

carotid artery stenosis greater than 70%
—angioplasty is used for high surgical risk

**Patients > 70yrs olf fare better w carotid endarterectomy

115
Q

What artery is associated with transient monocular blindness (Amaurosis fugax)

A

Internal Carotid pathology

116
Q

What artery is associated with dizziness and vertigo in a 67 year old woman w extensive atherosclerotic cerebrovascular disease?

A

Vertebrobasilar insufficiency

117
Q

What is the next diagnostic step that should be taken when Alzheimer dementia is suspected?

what is the best treatment?

A

Assess for depression and reversible causes of dementia

Tx: Acetylcholinesterase inhibitor (donepezil, rivastigmine, galantamine) +

NMDA receptor Antagonist (Memantine)

118
Q

What is the treatment of Anaphylaxis??

A
  1. First assess ABC’s (Airway, Breathing, Circulation)

2. Epinephrine (intramuscular in thigh)

119
Q

petechiae, vesicles, bullae, desquamation of the skin

  1. desquamation less than 10% of skin
  2. desquamation more than 30% of skin
A
  1. Steven Johnson syndrome

2. Toxic epidermal necrolysis

120
Q

In a patient with neutropenic fever, what should be done if infection is suspected to be from Catheter infection, skin/soft tissue infection, or mucositis?

what if the infection has no obvious source?

what if the fever persists?

A

Infection is probably gram-positive = IV Vancomycin plus antipseudomonal therapy

No obvious source = enteric gram negative = Antipseudomonal monotherapy (Cefepime, ciproflocacin, imipenem, beta-lactam + aminoglycoside)

persistent fever = Antifungal therapy (fluconazole, amphotericin B)

121
Q

What is the definition of neutropenia? what are chemotherapy patients at risk for?

A

absolute neutrophil count less than 500 cells/mm3

Neutropenic fever

122
Q

Which infectious agent is most likely associated with an infected central venous catheter in a neutropenic agent?

A

Staphylococcus epidermidis (coagulase negative)

123
Q

What is contraindicated in chemotherapy patients that are neutropenic?

A

Live vaccines (Varicella, Mumps)

124
Q

What micro-organism is most commonly associated with Septic Arthritis in of patients? (not sexually active)

A

S. aureus

125
Q

What microorganism is most commonly associated with septic bacterial arthritis in patients who are bit by another human?

A

Eikenella corrodens

126
Q

What is the criteria for Systemic inflammatory response syndrome (SIRS)?

A

2 or more of the following:

  1. Temperature >100.4 F (38C), < 96.8 F (36)C
  2. HR > 90 bpm
  3. RR >24 breaths/min
  4. leukocyte count > 12x10^3/mcL, <4x103/mcL or >10% bands
127
Q

What is septic shock?

A

“Severe Sepsis” (sepsis in a patient with signs of organ dysfunction)
+
unresponsive to fluid resuscitation for atleast 1 hour

128
Q

What is the pharm therapy for a immune suppressed patient with a colonoscopy revealing large atypical cells with intranuclear inclusion bodies?

A

CMV colitis - use ganciclovir

129
Q

What is the best initial imaging test for acute abdominal pain?

A

CT abdomen

130
Q

What is the Glasgow Coma Scale?

A 
Eye Opening
1-None
2-Response to Pain
3-Response to verbal command
4.Spontaneous

Verbal Response

  1. None
  2. Incomprehensible
  3. Inappropriate words
  4. Confused
  5. Oriented

Motor Response

  1. None
  2. Extension to pain
  3. Flexion to pain
  4. Withdrawal from pain
  5. Localizing to pain
  6. Obeys command
131
Q

What are the two most common precipitating factors for an adrenal crisis in a patient with Addison’s Disease?

A
  1. GI upset

2. Fever

132
Q

What is the management of an adrenal crisis?

A
  1. repletion of circulating glucocorticoids

2. correction of water deficit + electrolyte imbalances (hypertonic saline)

133
Q

What microorganism should be considered in a pregnant woman with meningitis?

A

Listeria monocytogenes

134
Q

What two microorganisms are comon causes of meningitis in patients following neurologic procedures (ie ventriculoperitoneal shunt)

A

S. aureus

S. epidermidis

135
Q

What are MRI findings in

  1. HSV meningitis
  2. TB meningitis?
A
  1. enhancement of temporal lobes

2. enhancement of basal region

136
Q

What is the type of TB infection where the Xray findings shows 1- to 2-mm granulomas?
What is a possible side effect?

A

Miliary TB - hematogenously disseminated tuberculosis
–adrenal involvement in common
=can cause ADRENAL INSUFFICIENCY

137
Q

How do you treat pregnant women with syphillis who are allergic to penicillin?

A

give penicillin after the women are desensitized

138
Q

what micro-organism is responsible in an HIV patient with pneumonia, nonproductive cough, elevated LDH?

What is the definitive diagnostic method?

A

Pneumocystis Jirovecii

Giemsa or silver stain

139
Q

What is the CD4 level diagnostic of AIDS?

A

CD4<200

140
Q

What prophylaxis should be given to an AIDS patient with a CD4 count of 180 cell/mm3

A

TMP-SMX to prevent pneumocytic pneumonia

141
Q

What is the cause and treatment for a HIV patient with new onset seizures. CT scan shows multiple ring-enhancing lesion of the brain.

A

Toxoplasmosis

Tx: Sulfadiazine with pyrimethamine

142
Q

What is the initial step in the management of acute pancreatitis?

A

(Early and aggressive fluid management) 0.9% Saline

143
Q

what is the NYHA classifications of Congestive Heart Failure?

A

Class I (Mild) - No limitation of physical activity

Class II (Mild) - slight limitation of physical activity, comfortable at rest, prolonged/moderate activity causes symptoms

Class III (Moderate) - marked limitation of physical activity. walking across room, getting dressed causes symptoms

Class IV (Severe) - Unable to carry out physical activity without discomfort

144
Q

What kind of kidney stones are formed in a patient with a hx of ileal resection for Crohn’s disease?

A

Oxalate stones

–malabsorption of bile acids = bile unavailable to bind oxalates

145
Q

complaining of RUQ abdominal pain. BP 75/46, HR 165/min, RR 18/min, O2 sat 97%, Temp 103.5 F. Phys exam shows scleral icterus and tenting of the skin. Elevated WBC’s

A

Ascending Cholangitis

Charcot’s triad (RUQ pain, fever, jaundice) starting to progress to Reynold’s Pentad (hypotension, altered mental status)

146
Q

What are patients with refractory H. pylori infections at risk for?

A

MALT lymphoma

147
Q

What ECG finding is associated with hypocalcemia?

A

prolonged QT interval

148
Q

A pt w chronic renal failure remains in the icu after a surgical procedure. The patient has diffuse microvascular bleeding from several puncture sites. Labs show normal PT/INR, aPTT, platelets.

what is the cause?

A

Coagulopathy from uremia.

—uremia causes platelet dysfunction - poor platelet adhesion

149
Q

A patient that was maced presents w post syncopal episode, itchy burning eyes/mouth/throat w facial rash., red, raised perioral rash

what was the offending agent?
what is another possible compound? (what symptoms)

A

Phenacyl chloride

pepper spray = Oleoresin Capsicum (capsaicin) = releases substance P
=inflammtion = lacrimation, rhinorrhea, coughing

150
Q

What are the stages of Chronic Kidney failure?

A

Assess by GFR

Stage 1: >90
Stage 2: 60-89
Stage 3: 30-59
Stage 4: 15-29
Stage 5: <15
151
Q

What is the diagnostic criteria for Amenorrhea

  1. primary
  2. secondary
A
  1. Absence of menarche by the age of 16

2. Absence of menstruation for 3 or more months in women w normal past menses

152
Q

What is the definition of Oligomenorrhea?

A

Menses occurring at infrequent intervals or more than 40 days or fewer than nine menses per year

153
Q

What is the most likely organism in a chronic smoker with pneumonia. productive cough w greenish sputum.. Febrile w normal CXR. gram stain reveals gram-negative cocci

A

Moraxella catarrhalis

154
Q

what is the treatment of an addisonian crisis?

A
  1. IV 5% glucose w normal saline to correct volume depletion and hypoglycemia
  2. corticosteroid therapy

(given salt, sugar, steroids)

155
Q

A pt on chronic corticosteroid therapy for SLE. I admitted to the hospital for a surgical procedure.
What is the most important intervention?

A

Hydrocortisone IV before surgery and every 6 hours for 24 hours
—prevent adrenal insufficiency before surgery

156
Q

What vitamin deficiency commonly accompanies Carcinoid syndrome?

A 
Vitamin B3 (Niacin) deficiency
---Both serotonin and B3 are synthesized from tryptophan
157
Q

What is the therapy for an acute Hepatitis B infection?

A

Antiviral therapy:

  1. Tenofovir
  2. Disoproxil
  3. Fumarate

–can also be used for an HIV infection too.

158
Q

A pt who recently had a new medication added to treat his cholesterol presents with acute gout. What was this medication?

A

Niacin

–Side fx: glucose intolerance, pruritis, elevated uric acid

159
Q

What is the next suggested step after taking lead blood levels in a child that has been ingesting lead pain chips

A

Plain film radiograph of the abdomen to detect retained lead objects that may require surgical intervention for removal.

160
Q

What is the CHADS2VASc score? what is it used for/how do you interpret it?

A

prevention of cardioembolic stroke

  1. Congestive heart failure - 1
  2. HTN - 1
  3. Age >75 - 2
  4. Diabetes Mellitus - 1
  5. Stroke or TIA - 2
  6. Vascular dz - 1
  7. Age 65-74 - 1
  8. Sc (Sex category) female = 1
0 = aspirin or no antithrombotis
1 = aspirin or anticoagulant (warfarin)
2+ = heparin bridged to warfarin to INR of 2-3
161
Q

What is the etiology of the pt sx:

62 year old male w abdominal pain and blood clots in stool. CT scan shows gastric varices + thrombus in splenic vein

A

Chronic pancreatitis - most common cause of Splenic vein thrombosis

Tx for gastric variceal bleeding secondary to splenic V thrombosis = splenectomy

162
Q

What is the USPSTF suggestion for screening for lung malignancy? in what patients?

A

low-dose helical scan of the chest
Adults 55-80 w >30 pack-year hx
+ currently smoke or quit within last 15 years

163
Q

What is the etiology of

A

Neuro Sx usually presenting during recovery from infection

  1. Localized low back pain
  2. sudden paresthesias in legs
  3. sensory loss, paraparesis
  4. urinary bladder and bowel dysfunction
  5. possible allodynia
164
Q

What is Ranson’s criteria?

A

Assess severity and predict mortality rate of acute pancreatitis

Admission:
glucose >200
Age > 55
LDH >350
AST > 250
WBC > 16000
Initial 48 hr exam:
calcium < 8
Decrease in HCT > 10%
PaO2 <60
Base deficit > 4mg
BUN increase  > 8mg/dL
Fluid sequestration >6L
165
Q

What is the managment of acute pericarditis?

A

NSAIDs,

Aspirin, Ibuprofen, Indomethacin

166
Q

What is the first line treatment of hyperkalemia with ECG changes?

A

Calcium gluconate

167
Q

what is the responsible organism:

HIV patient, noncompliant with meds, abdominal pain, bloody diarrhea, imaging shows free air under diaphragm

A

CMV colitis - mucosal perforation

168
Q

What therapy should be given to treat acute hypercalcemia in the following pt:
62 yr old woman, asymptomatic. hx of multiple myeloma, hypercalcemia. no bone lesions or end organ damage

A

Bisphosphonates - inhibits osteoclastic bone reabsorption

169
Q

what drug combo is helpful in the treatment of myeloma?

A

Dexamethasone + Thalidomide

170
Q

What is the most specific test for diabetes?
most sensitive?
most acceptable?

A

most specific: Fasting glucose: > 126 mg/dL
most sensitive: 2hr oral glucose tolerance test
Most acceptable dx test: HbA1c >6.5%

171
Q

What are the glycemic goals of Diabetic pts?

A

A1c <7%
preprandial glucose: 70-130 mg/dL
peak postprandial glucose < 180 mg/dL

172
Q

What vaccine should a patient recently diagnosed with DM Type II receive if not previously vaccinated?

A

Hepatitis B Vaccine

–DM confers a 60% higher infection rate versus nondiabetics

173
Q

How would you confirm the diagnosis of Graves disease?

what is the treatment?

A

Low serum TSH
High free T4

Tx: antithyroid drugs, radioactive iodine ablation, surgical removal of thyroid

174
Q

What is the treatment of choice for Graves disease in nonpregnant patients?

A 
non-pregnant = radioactive iodine
pregnant = PTU
175
Q

What distinguished hyperthyroidism from thyroid storm?

A

Fever and delirium (+bpm >140, fever (104-106))

176
Q

What lab test can confirm an acute transfusion reaction?

A

elevated LDH levels

177
Q

What is the therapeutic drug of choice for delirium tremens from alcohol withdrawal?

A

Benzodiazepines

178
Q

What is the best initial treatment of alcoholic ketoacidois?

A

infusion of 5% dextrose w 0.9% saline

179
Q

What is the underlying cause of a pt with ESRD and a easily fractured hip?

A

Hypovitaminosis D (impairment of absorption of Calcium in the GI tract

180
Q

What is the cause of 3.7g/day 24 hour protein in a patient with an acute hepatits B infection?

A

Membranous nephropathy

181
Q

What is the underlying cause of a DVT formation in a patient with nephropathy?

A

loss of antithrombin III in the urine

182
Q

What are most likely CXR findings in a patient with JVD, hepatojugular reflex, no crackles on lung auscultation, long hx of smoking?

A

Cor pulmonale = depressed diaphragm w prominent pulmonary artery

183
Q

What type of malignancy are pts with hashimotos thyroiditis at a higher risk for?

A

thyroid lymphoma

184
Q

what thyroid malignancy is associated with iodine deficiency?

A

Follicular carcinoma of the thyroid

185
Q

What are ECG findings in a Left bundle branch block?

A

QRS duration > 120 msec
no R wave in V1,
Wide + tall R waves in I, V5, V6

186
Q

What are the ECG two criteria for Left Ventricular hypertrophy

A

Sokolow-Lyon:
S (V1) + R (V5,V6) > 35

Cornell:
R (aVL) + S (V3) > 28(men) > 20(women)

187
Q

What is the most common cause of death in dialysis patients?

A

Cardiovascular disease

*also the most common cause of death in renal transplant patients

188
Q

What test would reveal the underlying etiology:

Pt with recurrent pneumonia infections, severe sinusitis, bloody diarrhea

A

Quantitative measurement of serum immunoglobulin levels

(pt may has Common variable immunodeficiency

189
Q

What are the two most common causes of Bacterial Meningitis in adults?

what is the tx?

A

N. meningitidis
S. Pneumoniae

Tx: Ceftriaxone, Cefotaxime

COMAT Exams (3 decks)

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