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
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
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)
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)
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
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
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
8
Q
What follow up actions should be taken to assess End organ damage from HTN?
A
- fundoscopic exam
- auscultation of major arteries for bruits
- Palpation of organs for enlargment
- check for lower extremity edema
9
Q
What is the most common cause of secondary HTN?
A
Renal dz
in young pts - think fibromuscular dysplasia
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)
11
Q
What are some criteria that suggest a dx of SIADH?
A
SIADH is a dx of exclusion
- Euvolemic
- Urine is not maximally dilute (150-200mmol/L)
- Urine sodium > 20mmol/L
- normal adrenal and thyroid function
12
Q
What is the strategy of choice for cardiogenic shock
A
Emergency PCI
13
Q
what is dx?
acute chest pain with free air under diaphragm on CXR
A
Perforated peptic ulcer
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
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
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
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
18
Q
what are the drugs of choice for congestive heart failure
A
ACE inhibitors
B-blockers
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
20
Q
Describe the 5 parts of Thrombotic Thrombocytopenic Purpura syndrome
What is the cause of TTP?
A
- microangiopathic hemolytic anemia
- thrombocytopenia
- neurologic abnormalities
- fever
- renal dysfunction
Cause = ADAMTS13 deficiency = excess vWF = microvascular thrombi
21
Q
Describe Hemolytic Uremic Syndrome
A
clinical complex consisting of
- progressive renal failure
- microangiopathic hemolytic anemia
- thrombocytopenia
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:
- rheumatoid arthritis
- neutropenia
- splenomegaly
- lymphadenopathy
- thrombocytopenia
Splenomegaly causes sequestration of platelets = thrombocytopenia
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
24
Q
what is the best intervention to slow the progression of Diabetic Nephropathy?
A
Angiotensin inhibition
- -ACE-i
- -ARB
25
what is the classic triad of acute cardiac tamponade
Beck's Triad:
1. Hypotension
2. elevated Jugular Venous Pressure
3. Small quiet heart
**Look for Pulsus Paradoxus (decrease of >10mmHg systolic w inspiration)
26
What was the most common cause of constrictive pericarditis in the US in the past?
what is the most common cause presently?
Tuberculosis
present: Radiation therapy, surgery, viral infection, uremia, malignancy
27
What cardiac condition is related to a pattern of alternating amplitude of QRS complexes
Electrical Alternans - Cardiac tamponade
28
What is the appropriate next step after suspecting pleural effusion from history and chest xray?
Diagnostic thoracocentesis - diagnose cause of the pleural effusion and determine the necessity for fluid drainage
29
What is the immediate support care for a patient with cardiac tamponade awaiting pericardiocentesis?
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
30
How do you interpret hematocrit levels of pleural fluid?
Hemothorax (trauma, malignancy) = pleural fluid HCT is >50% of Hct of peripheral blood
Cancer, PE, Tuberculosis (pleural Hct <50% Hct of peripheral blood)
31
What is the criteria to determine the difference between transudative and exudative fluid?
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
32
What fluid characteristics suggest the need for chest tube drainage? (6)
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
33
What is most appropriate next step when suspecting pulmonary edema?
Chest CT with intravenous contrast or other imaging study as indicated.
34
What is the most useful nonimaging diagnostic test for a PE?
D-dimer ELISA
35
What are ECG findings that suggest a PE?
usually: Sinus Tachycardia
rarely:
S1Q3T3 (inverted T wave in lead III)
36
What is the sequence of diagnostic tests used for diagnosing PE?
1. Chest CT
2. Lung Scan (V/Q)
3. Venous ultrasound to look for DVT
4. Transesophageal Echo
37
What is the best treatment for a DVT in a patient that presents with significant vaginal bleeding from cervical cancer?
vaginal bleeding = contraindication for anticoagulation
use Vena Cava filter
38
What is a side effect of biologic DMARDs TNF antagonists (etanercept, infliximab, adalimumab)
what should you do before prescribing?
increase risk of infection (reactivation of latent TB)
--pts should be screened for TB
39
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
Pseudogout
gout - NEGATIVELY birefringent crystals
40
What would synovial fluid show in a patient with Gonococcal arthritis?
elevated (>72,000) WBC's
| >75% Polymorphonuclear leukocytes
41
What location in the lung does:
1. primary pulmonary TB
2. reactivation TB
affect?
1. often in children - Middle and lower lobes
| 2. Apical and posterior segments of upper lobes
42
What disease is characterized by
asymptomatic or dysuria, hematuria, urinary frequency
+ the finding of leukocytes in the urine but negative bacterial cultures?
"Sterile pyuria" = Genitourinary TB
43
What are the tuberculin reaction sizes and the related circumstance required for diagnosis of latent M tuberculosis infection
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
44
What supplementation is often used along side Isoniazid?
Pyridoxine - prevent peripheral neuropathy
45
How is a latent TB infection treated?
Isoniazide for 9 months
46
Which testis the most important to follow for a patient receiving isoniazid and rifampin for TB treatment?
Liver function tests
47
What is the criteria for the diagnosis of at UTI in the elderly?
1. clean catch
2. specimen from catheterization
1. 10^5 colony-forming units
| 2. 10^2 colony-forming units
48
How does distributive shock differ from cardiogenic and hypovolemic shock?
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"
49
What is the intial management of an acute arterial occlusion?
Anticoagulation w heparin to prevent propagation of the thrombus
50
What the next best diagnostic step when COPD is suspected? what is the best initial treatment?
dx: ABG to assess oxygenation and acid-base status
tx: oxygen by nasal cannula,, bronchodilators and steroids for airway inflammation
51
What is the usual diagnostic criteria for COPD?
FEV1/FVC <70%
52
What therapy provides the greatest benefit to a patient with chronic stable emphysema and a resting oxygen sat of 86%
Supplemental oxygen used continuously
smoking cessation
--only medical therapies shown to decrease mortality among COPD pts
53
What type of movements are still present in a patient that is brain dead?
```
Spinal reflexes (outside the brainstem)
ex: facial nerve twitching, fasiculations of trunk/extremities
```
54
What is contraindicated in an unconscious patient that drank drain-O?
NPO - do not intubate - may exacerbate the damaged mucosa from the drain-O = can cause esophageal rupture
55
When should valve replacement be considered in a patient with aortic stenosis?
aortic valve with an area less than 1 cm2
56
The monitoring of which electrolyte is important in congestive heart failure?
Sodium - reduce sodium intake to control fluid retention
57
What is the therapy of choice for acute Otitis Media? when is observation appropriate?
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
58
When should tPA or surgical embolectomy be used as primary therapy for a PE?
When the pt is at high risk if the embolism stays
it pt has:
1. Right heart failure
2. Hypotension (systolic >90mmHg)
59
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?
```
Moderate persistent (daily symptoms, nocturnal awakenings >1/week)
--long acting B2-agonist = preferred therapy
```
60
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?
Mild persistent asthma (>2/wk;<1/day symptoms, >2/month nocturnal awakening)
--Low-dose inhaled steroids = preferred therapy
61
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?
Squamous Cell Cancer
- -produced PTH-like hormone
- ------causes hypercalcemia
typically CENTRAL/HILAR
62
What are extrapulmonary manifestations of Small Cell Lung Cancer?
SIADH
ectopic ACTH - Cushing
Eaton-Lambert
-peripheral neuropathy
63
What do most patients presenting with hemoptysis require?
bronchoscopy
| ---massive hemoptysis may result in death from asphyxiation
64
What is the management of a solitary pulmonary nodule in relation to size?
nodules <8mm = follow radiographically
| nodules >8mm = biopsy, consider surgical resection
65
what is the use of aztreonam?
used with patients with penicillin allergy for gram negative rod infections (ie pseudomonas)
66
What therapy should be administered in a patient with dry/cracked skin cellulitis? (what is the most likely pathogen)
most likely pathogen = Streptococci / Staphylococci
Nafcillin = first line therapy
67
How is FeNa calculated? how do you interpret results?
FeNa = 100x(Serum creatinine/Urine creatinine)/(Serum Sodium/Urine Sodium)
```
<1% = prerenal azotemia (ie volume depletion)
>2% = ATN, AIN
```
68
How is the BUN/serum CR ratio interpreted?
BUN/Cr >20:1 = pre-renal disease (ie volume depletion, renal A stenosis)
BUN/CR = normal or 10 to 15: 1 = ATN, AIN
69
How is urine Sodium interpreted in regards to kidney injury?
Urine sodium < 20 mmol/L = pre-renal azotemia
| Urine sodium > 40 mmol/L = ATN, AIN
70
What is the pharmacologic management of acute symptomatic hypocalcemia?
IV 10% Calcium gluconate
71
A pt treated for hypocalcemia with IV Calcium gluconate still shows hypocalcemia. What other electrolyte infusion should have been administered first?
Magnesium
--hypomagnesemia can cause PTH resistance
72
What criteria index used to risk-stratify pneumonia patients?
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
73
What is the typical outpatient therapy of community acquired pneumonia?
Macrolide Abx = Azithromycin, doxycycline, antipneumococcal quinolones (moxifloxacin, levofloxacin)
74
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.
Legionella pneumophila - typically presents w:
1. myalgias
2. abdominal pain
3. diarhea
4. severe pneumonia
* consider because of history of smoking
75
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
IV cefepime:
---nursing home = pneumonia is nosocomial not CAP
=high incidence of gram negative
---age, med hx = high risk = hosptialization and IV cephalosporin
76
What is the most appropriate management of aspiration pneumonitis?
Supportive care = observation w follow up CXR
77
what is the statistical advantage of a D-dimer? what does this mean?
very high negative predictive value
- can have false positives
- if ddimer is negative no further testing for PE
78
What is the lab test to check for the following causes of hepatitis:
1. Wilson disease
2. Hemochromatosis
1. Low serum ceruloplasmin
| 2. High transferrin saturation (>45%), high ferritin
79
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?
Pancreatic pseudocyst - presents as:
1. abdominal pain/mass
2. persistent hyperamylasemia
80
what is the pharm therapy for chronic hep B infection
interferon and oral Lamivudine
81
How does essential tremor usually present?
bilateral hand tremor (frequency 4 to 6 Hz) that exacerbates with actions
improvement: beta blockers, anticonvulsants, small amounts of alcohol
82
What is the most common electrolyte abnormality in diabetic ketoacidosis?
hyperosmolar HYPONATREMIA
| --from the plasma dilutional effect of hyperglycemia
83
A patient with DKA dies secondary to a cardiac arrest. correction of what electrolyte abnormality could have prevented this patients death?
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
What use is Zoledronic acid reserved for?
zoledronic acid = IV bisphosphonate
| --used for prevention of skeletal fractures in patients with Multiple Myeloma and Prostate Cancer
85
The feeding of a patient (alcoholic, anorexic, malnourished) causing generalized tremors of entire body with confusion.
what is the cause?
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
What does a more than 20:1 BUN:Cr ratio indicate about the type of kidney injury?
Prerenal failure
87
What is the next diagnostic step when Acute Kidney Injury is suspected from a high BUN:Cr level?
Urinalysis and urine chemistries to determine whether the process is prerenal or renal or postrenal (less likely)
88
What are the urinalysis findings of:
1. prerenal failure
2. postrenal failure (what microscopic findings for which types of obstruction)
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
What are urinalysis findings of Ischemic and Nephrotoxic ATN?
1. Isothenuric (urine osmolality is equal to serum osmolality)
2. proteinuria - containing muddy brown granular casts
90
What is the treatment of hyperkalemia?
C BIG K
| -Calcium, Bicarb/B-agonis, Insulin, Glucose, Kayexalate
91
What is the first line therapy for treating Osteoarthritis?
NSAIDs - NOT Acetominophen
92
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.
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
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?
Gout
| --male gender, diuretic use, alcohol abuse
94
acute onset knee pain, rhomboid shaped crystals, positively birefringent
Pseudogout - positively birefringent (blue in parallel light)
95
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
Acute lymphoblastic leukemia
96
How do you interpret the T-score of a DEXA scan?
```
Normal = Tscore > -1 Standard Deviation
Osteopenia = T-score of -1 to 2.5 SD
Osteoporosis = T-score less than 2.5 Standard dev
```
97
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
Tuberculous osteomyelitis (Pott disease)
98
What is the next best step in management:
| 45 year old man w saddle anesthesia and decreased ankle reflexes bilaterally?
Cauda equina syndrome - immediate referral for advandced imaging and surgical evaluation for decompression to avoid long-term denervation
99
What kind of kidney stone can be prevented with the acidification of urine (ie drinking cranberry juice)
Calcium Phosphate stones (form in alkaline urine)
100
right lower lobe nodule is found incidentally on CXR. follow up CT shows nodule to be 7mm with popcorn like calcification
what is dx?
Pulmonary Hamartoma - do not have malignant potential
| -composed of tissue elements normally found at site.
101
What is the highest risk factor for cervical cancer?
Multiple sex partners - contracting HPV 16, 18, 45, 33, 58
102
how do you differentiate arthritis from soft tissue disorders (ie cellulitis, or bursitis)?
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
What are the leukocyte levels in synovial fluid for:
1. Inflammatory
2. Septic?
1. leukocytes: 2000-75000
| 2. leukocytes: >100,000
104
In the case of inflammatory arthritis what does Chondrocalcinosis or linear calcium deposition in joint cartilage suggest?
Pseudogout
105
What preventative medication should be used in a patient with gouty arthritis and renal disease?
Febuxostat (Allopurinol needs to be given in lower doses in patients with renal insufficiency)
106
What diagnostic test should be used to dx a gonococcal cause of arthritis?
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
What is the most ideal site for a creation of an AV fistula for dialysis?
Radial artery
| Cephalic vein
108
What are abnormal Orthostatic vital signs?
Drop of:
20mmHg Systolic
10mmHg Diastolic
upon standing
109
What is the most appropriate diagnostic modality for a patient with a Syncopal event and normal physical exam?
24-hour Holter monitor
110
What are the characteristics of Coma?
Complete failure of arousal system
Reflexes, postural responses are intact
EEG shows auditory brainstem response
111
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?
Hyperkalemia - from Succinylcholine administration in burn patient
112
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?
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
What is the next step when a Transient ischemic attack is suspected?
what medication should be administered? in what time frame?
NONCONTRAST CT of the brain.
thrombolytics (IV recombinant tPA) - within 3-4.5 hours
114
When should carotid endarterectomy be performed?
carotid artery stenosis greater than 70%
---angioplasty is used for high surgical risk
**Patients > 70yrs olf fare better w carotid endarterectomy
115
What artery is associated with transient monocular blindness (Amaurosis fugax)
Internal Carotid pathology
116
What artery is associated with dizziness and vertigo in a 67 year old woman w extensive atherosclerotic cerebrovascular disease?
Vertebrobasilar insufficiency
117
What is the next diagnostic step that should be taken when Alzheimer dementia is suspected?
what is the best treatment?
Assess for depression and reversible causes of dementia
Tx: Acetylcholinesterase inhibitor (donepezil, rivastigmine, galantamine) +
NMDA receptor Antagonist (Memantine)
118
What is the treatment of Anaphylaxis??
1. First assess ABC's (Airway, Breathing, Circulation)
| 2. Epinephrine (intramuscular in thigh)
119
petechiae, vesicles, bullae, desquamation of the skin
1. desquamation less than 10% of skin
2. desquamation more than 30% of skin
1. Steven Johnson syndrome
| 2. Toxic epidermal necrolysis
120
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?
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
What is the definition of neutropenia? what are chemotherapy patients at risk for?
absolute neutrophil count less than 500 cells/mm3
Neutropenic fever
122
Which infectious agent is most likely associated with an infected central venous catheter in a neutropenic agent?
Staphylococcus epidermidis (coagulase negative)
123
What is contraindicated in chemotherapy patients that are neutropenic?
Live vaccines (Varicella, Mumps)
124
What micro-organism is most commonly associated with Septic Arthritis in of patients? (not sexually active)
S. aureus
125
What microorganism is most commonly associated with septic bacterial arthritis in patients who are bit by another human?
Eikenella corrodens
126
What is the criteria for Systemic inflammatory response syndrome (SIRS)?
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
What is septic shock?
"Severe Sepsis" (sepsis in a patient with signs of organ dysfunction)
+
unresponsive to fluid resuscitation for atleast 1 hour
128
What is the pharm therapy for a immune suppressed patient with a colonoscopy revealing large atypical cells with intranuclear inclusion bodies?
CMV colitis - use ganciclovir
129
What is the best initial imaging test for acute abdominal pain?
CT abdomen
130
What is the Glasgow Coma Scale?
```
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
What are the two most common precipitating factors for an adrenal crisis in a patient with Addison's Disease?
1. GI upset
| 2. Fever
132
What is the management of an adrenal crisis?
1. repletion of circulating glucocorticoids
| 2. correction of water deficit + electrolyte imbalances (hypertonic saline)
133
What microorganism should be considered in a pregnant woman with meningitis?
Listeria monocytogenes
134
What two microorganisms are comon causes of meningitis in patients following neurologic procedures (ie ventriculoperitoneal shunt)
S. aureus
| S. epidermidis
135
What are MRI findings in
1. HSV meningitis
2. TB meningitis?
1. enhancement of temporal lobes
| 2. enhancement of basal region
136
What is the type of TB infection where the Xray findings shows 1- to 2-mm granulomas?
What is a possible side effect?
Miliary TB - hematogenously disseminated tuberculosis
--adrenal involvement in common
=can cause ADRENAL INSUFFICIENCY
137
How do you treat pregnant women with syphillis who are allergic to penicillin?
give penicillin after the women are desensitized
138
what micro-organism is responsible in an HIV patient with pneumonia, nonproductive cough, elevated LDH?
What is the definitive diagnostic method?
Pneumocystis Jirovecii
Giemsa or silver stain
139
What is the CD4 level diagnostic of AIDS?
CD4<200
140
What prophylaxis should be given to an AIDS patient with a CD4 count of 180 cell/mm3
TMP-SMX to prevent pneumocytic pneumonia
141
What is the cause and treatment for a HIV patient with new onset seizures. CT scan shows multiple ring-enhancing lesion of the brain.
Toxoplasmosis
| Tx: Sulfadiazine with pyrimethamine
142
What is the initial step in the management of acute pancreatitis?
(Early and aggressive fluid management) 0.9% Saline
143
what is the NYHA classifications of Congestive Heart Failure?
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
What kind of kidney stones are formed in a patient with a hx of ileal resection for Crohn's disease?
Oxalate stones
| --malabsorption of bile acids = bile unavailable to bind oxalates
145
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
Ascending Cholangitis
Charcot's triad (RUQ pain, fever, jaundice) starting to progress to Reynold's Pentad (hypotension, altered mental status)
146
What are patients with refractory H. pylori infections at risk for?
MALT lymphoma
147
What ECG finding is associated with hypocalcemia?
prolonged QT interval
148
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?
Coagulopathy from uremia.
| ---uremia causes platelet dysfunction - poor platelet adhesion
149
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)
Phenacyl chloride
pepper spray = Oleoresin Capsicum (capsaicin) = releases substance P
=inflammtion = lacrimation, rhinorrhea, coughing
150
What are the stages of Chronic Kidney failure?
Assess by GFR
```
Stage 1: >90
Stage 2: 60-89
Stage 3: 30-59
Stage 4: 15-29
Stage 5: <15
```
151
What is the diagnostic criteria for Amenorrhea
1. primary
2. secondary
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
What is the definition of Oligomenorrhea?
Menses occurring at infrequent intervals or more than 40 days or fewer than nine menses per year
153
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
Moraxella catarrhalis
154
what is the treatment of an addisonian crisis?
1. IV 5% glucose w normal saline to correct volume depletion and hypoglycemia
2. corticosteroid therapy
(given salt, sugar, steroids)
155
A pt on chronic corticosteroid therapy for SLE. I admitted to the hospital for a surgical procedure.
What is the most important intervention?
Hydrocortisone IV before surgery and every 6 hours for 24 hours
---prevent adrenal insufficiency before surgery
156
What vitamin deficiency commonly accompanies Carcinoid syndrome?
```
Vitamin B3 (Niacin) deficiency
---Both serotonin and B3 are synthesized from tryptophan
```
157
What is the therapy for an acute Hepatitis B infection?
Antiviral therapy:
1. Tenofovir
2. Disoproxil
3. Fumarate
--can also be used for an HIV infection too.
158
A pt who recently had a new medication added to treat his cholesterol presents with acute gout. What was this medication?
Niacin
| --Side fx: glucose intolerance, pruritis, elevated uric acid
159
What is the next suggested step after taking lead blood levels in a child that has been ingesting lead pain chips
Plain film radiograph of the abdomen to detect retained lead objects that may require surgical intervention for removal.
160
What is the CHADS2VASc score? what is it used for/how do you interpret it?
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
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
Chronic pancreatitis - most common cause of Splenic vein thrombosis
Tx for gastric variceal bleeding secondary to splenic V thrombosis = splenectomy
162
What is the USPSTF suggestion for screening for lung malignancy? in what patients?
low-dose helical scan of the chest
Adults 55-80 w >30 pack-year hx
+ currently smoke or quit within last 15 years
163
What is the etiology of
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
What is Ranson's criteria?
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
What is the managment of acute pericarditis?
NSAIDs,
| Aspirin, Ibuprofen, Indomethacin
166
What is the first line treatment of hyperkalemia with ECG changes?
Calcium gluconate
167
what is the responsible organism:
| HIV patient, noncompliant with meds, abdominal pain, bloody diarrhea, imaging shows free air under diaphragm
CMV colitis - mucosal perforation
168
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
Bisphosphonates - inhibits osteoclastic bone reabsorption
169
what drug combo is helpful in the treatment of myeloma?
Dexamethasone + Thalidomide
170
What is the most specific test for diabetes?
most sensitive?
most acceptable?
most specific: Fasting glucose: > 126 mg/dL
most sensitive: 2hr oral glucose tolerance test
Most acceptable dx test: HbA1c >6.5%
171
What are the glycemic goals of Diabetic pts?
A1c <7%
preprandial glucose: 70-130 mg/dL
peak postprandial glucose < 180 mg/dL
172
What vaccine should a patient recently diagnosed with DM Type II receive if not previously vaccinated?
Hepatitis B Vaccine
| --DM confers a 60% higher infection rate versus nondiabetics
173
How would you confirm the diagnosis of Graves disease?
what is the treatment?
Low serum TSH
High free T4
Tx: antithyroid drugs, radioactive iodine ablation, surgical removal of thyroid
174
What is the treatment of choice for Graves disease in nonpregnant patients?
```
non-pregnant = radioactive iodine
pregnant = PTU
```
175
What distinguished hyperthyroidism from thyroid storm?
Fever and delirium (+bpm >140, fever (104-106))
176
What lab test can confirm an acute transfusion reaction?
elevated LDH levels
177
What is the therapeutic drug of choice for delirium tremens from alcohol withdrawal?
Benzodiazepines
178
What is the best initial treatment of alcoholic ketoacidois?
infusion of 5% dextrose w 0.9% saline
179
What is the underlying cause of a pt with ESRD and a easily fractured hip?
Hypovitaminosis D (impairment of absorption of Calcium in the GI tract
180
What is the cause of 3.7g/day 24 hour protein in a patient with an acute hepatits B infection?
Membranous nephropathy
181
What is the underlying cause of a DVT formation in a patient with nephropathy?
loss of antithrombin III in the urine
182
What are most likely CXR findings in a patient with JVD, hepatojugular reflex, no crackles on lung auscultation, long hx of smoking?
Cor pulmonale = depressed diaphragm w prominent pulmonary artery
183
What type of malignancy are pts with hashimotos thyroiditis at a higher risk for?
thyroid lymphoma
184
what thyroid malignancy is associated with iodine deficiency?
Follicular carcinoma of the thyroid
185
What are ECG findings in a Left bundle branch block?
QRS duration > 120 msec
no R wave in V1,
Wide + tall R waves in I, V5, V6
186
What are the ECG two criteria for Left Ventricular hypertrophy
Sokolow-Lyon:
S (V1) + R (V5,V6) > 35
Cornell:
R (aVL) + S (V3) > 28(men) > 20(women)
187
What is the most common cause of death in dialysis patients?
Cardiovascular disease
| *also the most common cause of death in renal transplant patients
188
What test would reveal the underlying etiology:
| Pt with recurrent pneumonia infections, severe sinusitis, bloody diarrhea
Quantitative measurement of serum immunoglobulin levels
| (pt may has Common variable immunodeficiency
189
What are the two most common causes of Bacterial Meningitis in adults?
what is the tx?
N. meningitidis
S. Pneumoniae
Tx: Ceftriaxone, Cefotaxime
