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USMLE Step 2 CK > Internal Medicine > Flashcards

Internal Medicine Flashcards

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USMLE® Step 1 flashcards
1
Q

What to think if question stem describes rapidly progressive respiratory symptoms (high-grade fever, chills, productive cough and SOB) in an alcoholic?

A

Acute respiratory distress secondary to acute pancreatitis!

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2
Q

Diagnosis of ARDS

A

A: Abnormal chest xray (bilateral lung opacities)
R: Rapid onset/progression of respiratory failure (within 1 week)
D: Decreased PaO2/FiO2 (ratio <300)
S: S&S are not attributable to CHF/fluid overload

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3
Q

Causes of ARDS

A

Pneumonia, aspiration, sepsis
Trauma
Acute pancreatitis

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4
Q

Management of ARDS

A

Mechanical ventilation (low TV, high PEEP)

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5
Q

Physiologic consequences of ARDS

A

1) Impaired gas exchange (V/Q mismatch as alveolar ventilation is zero)
2) Decreased lung compliance (loss of surfactant)
3) Increased pulmonary arterial pressure (due to hypoxic vasoconstriction in the lungs)

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6
Q

Describe the crystals found in synovial fluid analysis of gout?

A

Needle-shaped, negatively birefringent

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7
Q

Differentiating symptoms of cerebrovascular event vs acute flare of multiple sclerosis

A

Neurological deficits related to acute MS flare usually lasts for days to weeks.
Transient symptoms <24 hours (especially in patient with CVRF) are more likely to be a TIA.

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8
Q

Most common cause of anaemia in ESRF patient already given EPO?

A

Iron deficiency anaemia (iron rapidly depleted after EPO is given + iron stores already low in chronically ill patients)

Treat HD patients with IV iron.

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9
Q

What is the HbA1c target for optimal glycaemic control?

A

HbA1c <7.0%

Higher for older adults and those with comorbidities

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10
Q

When to start ACEi for renal protection in DM patients?

A

When patient has hypertension or increased albuminuria (albumin/creatinine ratio >30mg/g)

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11
Q

What tests should be included in evaluation of a first-time seizure?

A

Metabolic screen: glucose, electrolyte imbalance (RP, Ca, Mg)

Infective screen: CBC

Toxin screen: LFT (for alcohol use), toxicology screen

ECG (for underlying arrhythmias if LOC)

Neuroimaging (to rule out structural causes, e.g. tumour, stroke)

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12
Q

What is this?

  • Arthritic symptoms (joint pain, swelling) on second and third metacarpophalangeal joints and wrist
  • Onset <40 years old
  • Xray shows joint space narrowing, chondrocalcinosis, osteophytes
  • Comorbidities: diabetes, transaminitis
A

Arthropathy of hereditary haemochromatosis

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13
Q

Management of hereditary hemochromatosis arthropathy?

A

Symptomatic relief with NSAIDs

Phlebotomy is mainstay to prevent further joint injuries (does not reverse established arthropathy), and minimize systemic complications.

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14
Q

Criteria for initiating long-term home oxygen therapy in COPD patients?

A

1) Resting arterial oxygen tension (PaO2) <= 55mmHg or pulse oxygen saturation (SaO2) <=88% on RA
2) PaO2 <=59mmHg or SaO2 <=89% in patients with cor pulmonale, RHF, or hematocrit > 55%

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15
Q

What is this condition?

  • Young woman
  • Splenic infarction
  • Joint pain
  • Holosystolic murmur at apex
  • Thrombocytopenia
A

SLE!

Splenic infarction could have been caused by splenic artery thrombosis or embolism from nonbacterial thrombotic endocarditis.

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16
Q

Possible etiologies of splenic infarction?

A

1) Thrombosis secondary to hypercoagulable state (e.g. SLE, antiphospholipid syndrome, malignancies)
2) Embolism due to AF, IE, atheroma
3) Haemoglobinopathy (e.g. SCD)

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17
Q

Clinical presentation of Factor V Leiden mutation?

A

Venous thromboembolisms (DVTs, cerebral vein thrombosis).

Minimal association between Factor V Leiden and arterial thrombosis.

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18
Q

Notable adverse effect of IV nitroprusside given during hypertensive emergency?

A

Cyanide toxicity

  • Nitroprusside is metabolised into nitric oxide (causes vasodilation) and cyanide ions
  • Cyanide toxicity occurs at:
    1) Higher doses
    2) Prolonged infusion
    3) Existing renal insufficiency
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19
Q

S&S of cyanide toxicity?

A

Altered mental status, seizures, coma, lactic acidosis

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20
Q

Chronic lymphocytic leukaemia with anaemia and high reticulocyte count - what is the condition CLL is associated with?

A

Warm AIHA

(Anaemia with reticulocytosis usually = acute bleeding or haemolysis. Generally means there is no deficiency in folate, vitamin B12, iron)

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21
Q

Chronic cough that worsens overnight, did not improve with antihistamine therapy. No other significant S&S.

A

Suspect asthma. Evaluate with pulmonary function tests.

Alternatively, treat empirically with 2-4 weeks of inhaled glucocorticoids. Diagnosis can be made with improvement.

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22
Q

What is the diagnosis?

  • Elderly male with DM
  • Severe, unrelenting ear pain that is worse at night and on chewing
  • Otorrhea
  • Granulation tissue in external auditory canal
  • Lower CN deficits
A

Necrotizing (malignant) otitis externa

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23
Q

Treatment for necrotizing otitis externa?

A

Anti-pseudomonal agent (ciprofloxacin is drug of choice)

Surgical debridement of necrotic bone if not responsive to medical therapy

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24
Q

Treatment for postinfarction pericarditis?

A

Ibuprofen + colchicine!

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25
Q

Medical therapy for unstable angina/NSTEMI

A

1) DAPT (aspirin + clopidogrel)
2) Anticoagulation (heparin) for first 48 hours
3) Symptomatic (morphine, nitrates)
4) Secondary prevention (ACEi, b-blockers, statins)

26
Q

Extrarenal manifestations of ADPKD?

A 
Cerebral aneurysms
Cardiac valvular disorders (MR, AR)
Hepatic or pancreatic cysts
Inguinal hernias
Colonic diverticula
27
Q

Treatment for HOCM?

A

Beta blockers, non-dihydropyridine Ca channel blockers

ICD if high risk

28
Q

Persistent elevation in AST and ALT, high gamma gap (total protein - albumin = >4). What is this?

A

Autoimmune hepatitis

High gamma gap is due to high level of immunoglobulin

29
Q

What condition should be suspected in the following stem?

  • Elderly patient
  • Severe lymphocytosis with lymphocytes predominance
  • Hepatosplenomegaly
  • Lymphadenopathy
  • Bi-cytopenia (anaemia and thrombocytopenia)
A

Chronic lymphocytic leukaemia

30
Q

How is CLL diagnosed?

A

By flow cytometry

31
Q

What are the similarities and differences between oral leukoplakia and oral SCC?

A

Both have similar risk factors: smoke, alcohol-use.

Leukoplakia presents as white plaques on the buccal mucosa/tongue that cannot be scraped off. SCC presents as erosive or ulcerative lesions with surrounding erythema and/or induration, regional lymphadenopathy may be present.

32
Q

What is status epilepticus defined as?

A

Seizures lasting for >5 minutes or >2 seizures without completely regaining consciousness

33
Q

What are the common etiologies of status epilepticus?

A

Structural brain abnormalities (e.g. brain tumour), metabolic abnormalities, infection, drug withdrawal, non-compliance to anti-epileptic medications

34
Q

What is the management of status epilepticus?

A

1) Stabilize (ABCs, rapid neurologic evaluation, fingerstick glucose)
2) Terminate seizure: IV lorazepam
3) Prevent further recurrence: Non-benzo anti-epileptic drug (e.g. phenytoin, valproic acid, levetiracetam)
4) Once stabilized, neuroimaging to rule out structural causes, ischaemia or bleed

*Continuous EEG is indicated for those who do not regain consciousness after medical therapy - rule out non-convulsive status epilepticus

35
Q

What is the recommended screening guidelines for FAP?

A

Annual sigmoidoscopies for children starting at 10-12 years old, followed by annual colonoscopies once colorectal adenomas are detected.

Regular screening for upper GI tumours.

36
Q

When is proctocolectomy indicated in patients with FAP?

A

Proctocolectomy should be performed in patients who present with:

  • CRC or adenomas with high-grade dysplasia
  • Severe symptoms from colonic neoplasia (e.g. haemorrhage)
  • Significant increase in polyp number during screening interval.

Otherwise, urgent surgery is NOT indicated in all FAP patients and can be delayed until their early 20s.

37
Q

Solitary pulmonary nodule noted on CXR. What is the next best step?

A

Compare to previous chest x-ray -> no further action required if present >2 years ago.

If no previous CXR available or possible nodule growth, perform a chest CT.

38
Q

Bronchoscopy is preferred for biopsy of ______-located lesions, while CT-guided percutaneous biopsy is best for biopsy for ______-located lesions.

A

Bronchoscopy is preferred for biopsy of centrally-located lesions, while CT-guided percutaneous biopsy is best for biopsy for peripherally-located lesions.

39
Q

Physical examination findings in severe AS

A

Pulsus parvus et tardus
Late-peaking, crescendo-decrescendo systolic murmur at aortic area (Peak of blood flow occurs later as greater pressure is required to overcome thickened valves)
Soft and single S2 (soft and delayed closure due to thickened valve, almost to the same time as pulmonic valve)

40
Q

What are the side effects of amiodarone?

A

Hepatotoxicity
Pulmonary fibrosis
Hyper/hypothyroidism
Photodermatitis (corneal and blue-grey skin deposits)
Peripheral neuropathy
CVS effects: bradycardia, heart block (but less risk of torsades)

41
Q

What are the side effects of methimazole?

A 
Skin rash
Agranulocytosis
Aplastic anaemia
Hepatotoxicity
Teratogenic
42
Q

What are the side effects of digoxin?

A 
GI symptoms (nausea, diarrhoea, anorexia)
Visual disturbances
43
Q

What are the drugs that can cause drug-induced SLE?

A 
Classically:
Sulfonamide
Hydralazine
Isoniazid
Procainamide

Newer:
Etanercept
Infliximab

44
Q

Apart from cardiac tamponade, what other conditions may cause pulsus paradoxus?

A

Asthma, COPD, OSA
Croup
Pericarditis

45
Q

Characteristics of pleural fluid studies in:

1) TB effusions
2) Empyema

A

1) TB effusions: Very high protein levels (>4g/dL), low glucose levels (<60mg/dL) and lymphocytic leukocytosis
2) Empyema: Prominent neutrophilic leukocytosis (>50,000)

46
Q

Most common etiologies for SVC syndrome

A 
Granulomatous infections (e.g. TB, histoplasmosis)
Lung malignancies
47
Q

What is the most common mononeuropathy in patients on haemodialysis and what are the causes?

A

Carpal tunnel syndrome

Causes:

  • Dialysis-related amyloidosis
  • Increased venous pressure during haemodialysis
  • Deposition of calcium phosphate in tunnel
48
Q

What are the signs and symptoms of acute iron poisoning (and why they occur)?

What is the treatment for acute iron poisoning?

A

S&S:

  • Abdominal pain
  • GI bleeding
  • Shock and HAGMA
  • Liver necrosis

Iron directly injures GI mucosa by free radical production and lipid peroxidation, causing GI bleeding, shock and lactic acidosis.

Treatment: Deferoxamine

49
Q

When is antibiotic prophylaxis for IE indicated?

A

IE prophylaxis is indicated only in high-risk cardiac conditions, including:

  • Previous history of IE
  • Prosthetic heart valves
  • Structurally abnormal valve in a transplanted heart
  • Certain congenital heart disease (e.g. unrepaired cyanotic CHD, repaired CHD with residual defects, repaired CHD with prosthetic material within 6 months of repair)

Low-risk cardiac conditions (e.g. acquired valvular dysfunction, MVP, ASD, bicuspid valve) do not require prophylaxis.

50
Q

What clinical features suggest a malignant pleural effusion?

A

UNILATERAL pleural effusion
Large and non-painful effusion
Rapid weight loss
History of cancer

51
Q

Drug of choice in AF

A

Rate-control (for AF with rapid ventricular response):

  • B-blocker (e.g. metoprolol)
  • Non-dihydropyridine Ca channel blocker (e.g. verapamil)

Rhythm-control (esp. in younger patients):

  • Class Ic agents (flecainide, propafenone)
  • Class III agents (amiodarone, dofetilide)

Anticoagulation (based on CHADSVAS score)

52
Q

List precipitating factors of hepatic encephalopathy

A

1) Drugs (e.g. benzodiazepines, narcotics)
2) Infections (e.g. pneumonia, UTI, SBP*)
3) Increased nitrogen load (e.g. GI bleeding, increased dietary protein intake)
4) Electrolyte abnormalities (e.g. hypokalaemia)

53
Q

Initial treatment for hyperkalaemia?

A

Calcium gluconate - stabilizes cardiac cell membrane

54
Q

Explain how hypothyroidism can cause amenorrhea?

A

Low T3/T4 causes increase in TRH, which increases prolactin production, which in turn suppresses ovulation

55
Q

Drug of choice to treat hypertriglyceridemia

A

Fibrates (fenofibrate, gemfibrozil)

56
Q

Drug of choice to treat hyperlipidaemia

A 
Statins
PCSK9 inhibitors (Evolocumab, Alirocumab) - expensive

Ezetimibe and cholestyramine not as effective.
Cholestyramine may even increase triglycerides levels.

57
Q

Which are the drugs that decreases mortality and increase long term survival in patients with heart failure?

A

ACEi/ARBs
Beta-blockers (specifically, carvedilol, bisoprolol, and metoprolol)
Aldosterone antagonists (spironolactone)

Combination of hydralazine and nitrates in African-american

58
Q

What is treatment for Torsades de Pointes?

A

Magnesium sulphate

59
Q

What is the treatment for Lyme Disease?

A

Skin/mild disease - oral antibiotics (doxycycline)

Cardiac/neurologic disease - IV antibiotics (e.g. ceftriaxone)

60
Q

Hypercalcaemic crisis - manifestations?

A

Oliguria/anuria and altered mental status (obtunded, coma)

Often happens only if serum calcium level >14, which rarely occurs except in the setting of malignancy.

USMLE Step 2 CK (6 decks)

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