Internal Medicine: UWorld

Question 1

A patient presents with the symptoms below. What is the patient suffering from?

1. Non-inflammatory edema of the face, limbs, genitalia
2. Laryngeal edema
3. Edema of the bowels resulting in colicky abdominal pain

Answer 1

Angioedema

Question 2

What is the drug of choice in patients who present with hypertension and a benign essential tremor?

Answer 2

Propranolol

Propranolol is a non-selective beta-blocker that is effective in reducing the tremor probably by blocking beta-2 receptors

Question 3

Electrical alterans (the swinging motion of the heart in the pericardial cavity causes a beat-to-beat variation in QRS axis and amplitude) is a pathognomonic finding for what?

Answer 3

Pericardial effusion

Question 4

What is the treatment for asymptomatic pre-ventricular contractions (PVCs) that develop in a patient following an MI?

Answer 4

Observation (no treatment indicated)

PVCs are common in patients post-MI and can be recognized by their widened QRS (>120msec), bizarre morphology, and compensatory pause. Even though they may indicate a worse prognosis, treatment is not indicated unless the patient is symptomatic

Question 5

What are the first 2 steps in management of a patient with cirrhosis?

Answer 5

1. Screening endoscopy
2. Abdominal ultrasound

Screening endoscopy is done to exclude varices, indicate the risk of variceal hemorrhage, and determine strategies (I.E. nonselective beta blockers) for primary prevention of variceal hemorrhage. All patients with cirrhosis, regardless of etiology, should also undergo surveillance for hepatocellular carcinoma with ultrasound every 6 months.

Question 6

How is a pancreatic pseudocyst best diagnosed?

Answer 6

Ultrasound

The pancreatic pseudocyst is an encapsulated area comprised of enzyme-rich fluid, tissue, and debris that accumulates within the pancreas and causes an inflammatory response. It tends to resolve spontaneously.

Question 7

Nearly 90% of patients with essential mixed cryoglobulinemia have what disease?

Answer 7

Hepatitis C

Essential mixed cryoglobulinemia is due to circulating immune complexes that deposit in small to medium vessels and may be associated with low serum complement levels.

Question 8

Neck pain, fever, trismus (inability to open the mouth normally), and limited cervical extension could be indicative of what?

Answer 8

Retropharyngeal abscess

Question 9

Paget’s disease of the breast should be suspected in a patient with no prior history of skin disease who presents with an eczematous rash near the nipple that does not improve with topical treatments. The majority of these patients have what underlying process?

Answer 9

Breast adenocarcinoma

Skin biopsy will typically demonstrate large cells that appear to be surrounded by clear halos because the cancer cells become retracted from adjacent keratinocytes.

Question 10

What should be performed in all post-operative patients with oliguria and acute renal failure?

Answer 10

Urgent bladder scan and catheterization

This is due to suspected bladder outlet obstruction in the postoperative setting. Placement of a bladder catheter in a timely fashion can rapidly improve symptoms, reverse acute renal failure, and prevent long-term renal damage.

Question 11

Pain and stiffness in the neck, shoulders, and pelvic girdle in a patient over age 50 with an elevated ESR and morning stiffness lasting over one hour is indicative of what?

Answer 11

Polymyalgia Rheumatica

Question 12

What jaundice-causing complication can occur following a prolonged surgery characterized by hypotension, extensive blood loss into tissues, and massive blood replacement?

Answer 12

Postoperative cholestasis

Question 13

The following findings are consistent with what diagnosis?

1. Fatigue
2. Itching
3. Jaundice
4. Weightloss
5. Elevated alkaline phosphatase levels
6. Positive antimitochondrial antibody test

Answer 13

Primary biliary cirrhosis

Question 14

Heinz bodies on peripheral blood smear is suggestive of what diagnosis?

Answer 14

Glucose-6-phosphate dehydrogenase (G6PD) deficiency

G6PD is an enzyme involved in creating NADPH, a cofactor required to create glutathione and prevent the oxidation of hemoglobin. Without G6PD, hemoglobin becomes oxidized and denatures into Heinz bodies. The denatured hemoglobin disrupts red blood cell membranes and causes hemolysis.

Question 15

An isolated, round, smooth-bordered, ring-enhancing intracranial lesion on contrast CT scan of the brain in an immunocompetent patient with a known extracranial bacterial infection is most likely what?

Answer 15

A brain abscess

Question 16

What is the most commonly used tumor marker for pancreatic cancer?

Answer 16

Cancer antigen (CA) 19-9

This has a sensitivity and specificity of 80-90%. The CA 19-9 can be elevated in patients with jaundice but no pancreatic cancer, however, which reduces its utility as a screening tool. Postoperative monitoring of pancreatic cancer with CA 19-9 may be helpful in evaluating the tumor response to chemotherapy.

Question 17

What syndrome is characterized as an autosomal dominant disorder caused by germline mutations involving the RET proto-oncogene located on chromosome 10?

Answer 17

Multiple endocrine neoplasia (MEN) type 2

MEN 2A is associated with medullary thyroid cancer, pheochromocytoma, and parathyroid hyperplasia. MEN 2B patients can develop medullary thyroid cancer, pheochromocytoma, marfanoid habitus, and intestinal or mucosal neuromas.

Question 18

What is the treatment of choice for anemia secondary to end stage renal disease?

Answer 18

Recombinant erythropoietin

The major cause of anemia in patients with end stage renal disease is deficiency of erythropoietin.

Question 19

What diagnosis is suggested by a toxic appearance, fever, nausea, vomiting, flank pain, dysuria, and costovertebral tenderness?

Answer 19

Acute pyelonephritis

Urinalysis shows bacteriuria and pyuria. Urine culture reveals greater than 10,000 colonies/mL.

Question 20

What is a simple and effective way to reduce the formation of decubitus ulcers?

Answer 20

Patient repositioning every 2 hours

Question 21

D-xylose test is used to assess what?

Answer 21

The absorptive capacity of the proximal small intestine

Patients with proximal small intestinal mucosal disease (I.E. Celiac Sprue) cannot absorb the D-xylose in the intestine. As a result, the D-xylose does not reach the kidneys and is instead excreted in the feces. These patients typically have decreased urinary and serum D-xylose concentrations.

Question 22

Which autoimmune condition is characterized by non-caseating granulomas?

Answer 22

Crohn’s disease

This is not a feature of ulcerative colitis.

Question 23

Declining serum transaminase levels in the setting of a rising prothrombin time is suggestive of what?

Answer 23

Progression to fulminant hepatitis

A rise in Prothrombin time (PT) with a decrease in transaminase levels implies that very little functional tissue remains in the liver, which can happen rapidly in cases of fulminant hepatic failure. PT is considered the single most important test to assess the function of the liver because all clotting factors (except for factor VIII) are synthesized in the liver. When the liver is unable to create sufficient amounts of clotting factors, the PT is prolonged.

Question 24

What condition usually presents in childhood as palpable purpura on the buttocks, abdominal pain, arthralgias, proteinuria, and hematuria with red blood cell casts on urinalysis?

Answer 24

Henoch-Schonlein purpura

Serum complement levels are normal in this condition.

Question 25

What 2 organisms are most commonly cultured from the ascites fluid of a patient with spontaneous bacterial peritonitis?

Answer 25

1. E. Coli 2. Klebsiella ## Footnote *Enteric organisms are the most common. Empiric therapy is generally with a 3rd generation cephalosporin.*

Question 26

A prolonged QT interval suggests what?

Answer 26

Tachyarrhythmia

Question 27

What test has replaced the lactose tolerance test?

Answer 27

Lactose hydrogen breath test ## Footnote *The lactose tolerance test is cumbersome and time consuming. A positive hydrogen breath test is characterized by a rise in the measured breath hydrogen level after ingestion of lactose, thus indicating bacterial carbohydrate metabolism.*

Question 28

High-dose niacin therapy to treat lipid abnormalities frequently produces cutaneous flushing and pruritis. What is the mechanism for this side effect and what prophylactic drug can be administered to reduce it?

Answer 28

The side effect is explained by prostaglanding-induced peripheral vasodilation and can be reduced by low-dose aspirin

Question 29

What is the first line medical treatment for idiopathic benign intracranial hypertension?

Answer 29

Acetazolamide *It inhibits choroid plexus carbonic anhydrase and thus reduces CSF production and intracranial hypertension*

Question 30

Megacolon/megaesophagus and cardiac disease are the two primary manifestations of what?

Answer 30

Chagas disease (Trypanosoma cruzi) *Megacolon/megaesophagus occur secondary to destruction of the nerves controlling the GI smooth muscle. The pathophysiology of Chagas heart disease is not well understood, but probably represents a prolonged myocarditis secondary to the protozoal infection*

Question 31

Thrombotic thrombocytopenic purpura (TTP) is due to decreased activity of what?

Answer 31

ADAMTS-13 ## Footnote *TTP is thought to be due to a deficiency of or autoantibody against a specific von Willebrand factor-cleaving protease called ADAMTS-13. This causes the accumulation of large von Willebrand factor multimers and platelet aggregation. Patients can develop fever, microangiopathic hemolytic anemia, thrombocytopenia with possible purpura, renal failure, and neurologic findings (I.E. headache, confusion). TTP does not usually decrease complement levels.*

Question 32

Hypertensive emergency is defined as marked, severe hypertension associated with what (more specific than end-organ damage)?

Answer 32

Malignant hypertension (retinal hemorrhages, exudates, and/or papilledema) or hypertensive encephalopathy (cerebral edema)

Question 33

Patients who have recieved the equivalent of more than one blood volume of blood transfusions or packed red blood cells over 24 hours may develop elevated plasma levels of what substance?

Answer 33

Citrate ## Footnote *Citrate is an anticoagulant that is added to stored blood. Citrate chelates calcium and magnesium and may reduce their plasma levels, causing paresthesias.*

Question 34

What is the post-exposure prophylaxis for hepatitis B in an unvaccinated individual?

Answer 34

Hepatitis B vaccine + Hepatitis B immune globulin ## Footnote *This should be administered as soon as possible.*

Question 35

What antihypertensive class can worsen cardiac ischemia?

Answer 35

Dihydropyridine calcium channel blockers *They cause peripheral vasodilation and reflex tachycardia*

Question 36

Winter's Formula

Answer 36

P_aCO₂ = 1.5 (HCO₃^-) + 8 *Winter's formula can be used to calculate the expected PCO2 during respiratory compensation for a primary metabolic acidosis.*

Question 37

What helps differentiate between liver and cardiac causes of lower extremity edema?

Answer 37

Hepato-jugular reflex is positive in cardiac etiologies

Question 38

What is the first step in managing a patient with atrial fibrillation with rapid ventricular response?

Answer 38

Rate control with a beta-blocker or a calcium channel blocker ## Footnote *Immediate synchronized electrical cardioversion is indicated in hemodynamically unstable patients with rapid atrial fibrillation*

Question 39

What is the cause of hypoxia in a patient with pneumonia?

Answer 39

Alveolar and interstitial inflammation which causes areas of V/Q mismatch. This manifests as an increase in the alveolar-arterial oxygen gradient.

Question 40

What is the most important contributor to edema in heart failure patients?

Answer 40

Increased renal sodium retention *This results from the activation of the renin-angiotensin-aldosterone system as a result of hypoperfusion secondary to decreased cardiac output*

Question 41

In general, what is the best antibiotic for infectious diarrhea?

Answer 41

Ciprofloxacin ## Footnote *It is unlikely that ampicillin will cover any organisms that Ciprofloxacin does not, but oral ampicillin is used to treat some cases of infectious diarrhea.*

Question 42

What is the treatment for an amebic liver abscess?

Answer 42

Oral metronidazole ## Footnote *Because of its associated risks, cyst aspiration is not typically recommended unless the patient fails therapy. Surgical resection of a hepatic amebic abscess is not usually first-line treatment because it is associated with numerous risks. Surgical intervention may be indicated when the abscess has ruptured, eroded into adjacent structures, or caused extrahepatic complications, such as small bowel obstruction.*

Question 43

The following findings are consistent with what diagnosis? 1. Medullary thyroid cancer 2. Pheochromocytoma 3. Mucosal and intestinal neuromas 4. Marfanoid habitus

Answer 43

Multiple Endocrine Neoplasia (MEN) type 2B

Question 44

What is a common cause of acute onset monoarthropathy of the knee (often in the setting of hyperparathyroidism)?

Answer 44

Pseudogout

Question 45

What is the study of choice for diagnosis and follow-up of abdominal aortic aneurysms?

Answer 45

Abdominal ultrasound *It has nearly 100% sensitivity and specificity for this condition.*

Question 46

What is the inheritance pattern of Crigler-Najjar syndrome?

Answer 46

Autosomal recessive ## Footnote *This is a very rare disease characterized by significant unconjugated hyperbilirubinemia. Phototherapy or plasmapheresis are typically helpful in the short term, with liver transplant the only curative option.*

Question 47

What is the most common cause of secondary hypertension?

Answer 47

Renal artery stenosis *Associated with a continuous periumbilical murmur on physical exam*.

Question 48

What is recommended for all patients with unexplained gross hematuria or with microscopic hematuria and other risk factors for bladder cancer?

Answer 48

Cystoscopy ## Footnote *Other indications for cystoscopy include recurrent urinary tract infections, obstructive symptoms with suspicion for stricture or stone, irritative symptoms without urinary infection, and abnormal bladder imaging or urine cytology.*

Question 49

What is the first treatment of choice in patients with symptomatic sinus bradycardia who are hemodynamically unstable?

Answer 49

IV epinephrine

Question 50

Normal amounts of total urinary coproporphyrin composed of over 80% coproporphyrin I is a finding suggestive of what diagnosis?

Answer 50

Dubin-Johnson Syndrome ## Footnote *Normal individuals have urinary coproporphyrin composed primarily (80%) of coproporphyrin III.*

Question 51

Worsening post-prandial pain that leads to avoidance of food and a resultant weight loss is characteristic of what?

Answer 51

Chronic mesenteric ischemia due to occlusion (atherosclerosis) of visceral arteries (abdominal angina)

Question 52

What is important in treating patients with right heart failure secondary to right ventricular infarction?

Answer 52

IV fluids and avoidance of preload reducing medications such as nitrates and diuretics *These patients are preload dependent and dropping preload can be catastrophic*

Question 53

1. What is the name of the triad of hypotension, distended neck veins, and muffled heart sounds? 2. What does this triad indicate?

Answer 53

1. Beck's Triad 2. Cardiac Tamponade

Question 54

What is the leading cause of end stage renal disease in the United States?

Answer 54

Diabetic nephropathy ## Footnote *Diabetic nephropathy is characterized by increased extracellular matrix, basement membrane thickening, mesangial expansion, and fibrosis.*

Question 55

An important complication of nephrotic syndrome is renal vein thrombosis. How does it present?

Answer 55

1. Sudden onset abdominal pain 2. Fever 3. Hematuria

Question 56

Hypogonadism, arthropathy, diabetes, and hepatomegaly in the setting of dilated cardiomyopathy, heart failure or cardiac conduction abnormalites is characteristic of what?

Answer 56

Hereditary hemochromatosis *Abnormal iron deposition in various organs, leading to multisystem end-organ damage*.

Question 57

Paroxysmal, lightning-like pain on the face is usually due to what?

Answer 57

Trigeminal neuralgia

Question 58

Fever, painful enlargement of the testes, and irritative voiding symptoms are characteristics of what diagnosis?

Answer 58

Acute epididymitis ## Footnote *Acute epididymitis in younger patients is usually caused by sexually transmitted organisms such as C. Trachomatis or N. gonorrhea. In older men it is usually non-sexually transmitted and is caused by gram-negative rods.*

Question 59

Clear lung fields, hypotension, and jugular venous distension in the setting of an inferior wall MI are suggestive of what?

Answer 59

Right ventricular infarct

Question 60

What is used to treat low fibrinogen states?

Answer 60

Cryoprecipitate ## Footnote *Cryoprecipitate contains fibrinogen.*

Question 61

What disease is characterized as a necrotizing inflammation of medium-sized arteries and occasionally the small muscular arteries?

Answer 61

Polyarteritis nodosa (PAN) ## Footnote *Patients can present with systemic symptoms (I.E. fever, malaise, and weight loss), neuropathy, arthralgias or myalgias, cutaneous findings (I.E. livedo reticularis), or renal disease.*

Question 62

What is the diagnostic test for diffuse esophageal spasm (DES)?

Answer 62

Manometry ## Footnote *Spontaneous pain (that resolves with nitroglycerin) and odynophagia for cold and hot food are suggestive of DES. Esophageal manometry should reveal repetitive, non-peristaltic, high amplitude contractions, either spontaneously or after ergovine stimulation. Nitrates (and other calcium channel blockers) reduce pain because they relax not only the myocytes in the vessels, but also all others, including those in the esophagus.*

Question 63

a seizure, as compared to a syncopal episode, is likely to be associated with what?

Answer 63

1. Confusion following episode of loss of consciousness 2. Bitten tongue after episode 3. Sore muscles after episode

Question 64

Which condition causes the clinical triad of systemic vasculitis, upper and lower airway granulomatous inflammation, and glomerulonephritis? Common external manifestations include nasal cartilage destruction and vasculitic cutaneous lesions (tender nodules, palpable purpura, and ulcerations).

Answer 64

Granulomatosis with polyangiitis (Wegener's Granulomatosis)

Question 65

Multiple episodes of thrombosis in a young patient without a clear precipitating factor should raise concern for hypercoagulability due to what?

Answer 65

Genetic defect (I.E. Deficiencies of Protein C, Protein S, or Antithrombin III) ## Footnote *In an elderly patient, this would be more suggestive of a primary malignancy.*

Question 66

What is the first step in the initial ventilator management of ARDS?

Answer 66

Decrease FiO2 to relatively non-toxic values ( \<60%) *Positive End Expiratory Pressure (PEEP) can be increased as needed to maintain adequate oxygenation after the FiO2 is lowered*. *Mechanical ventilation improves oxygenation by providing an increased fraction of inspired oxygen (FiO2) and by providing PEEP to prevent alveolar collapse. In the hospital setting, the arterial pO2 provides an important measure of oxygenation. It is influenced mainly by the FiO2 and PEEP level. The arterial pCO2, a measure of ventilation, is affected mainly by the respiratory rate and tidal volume. Patients are often provided a high FiO2 (\>80%) initially in mechanical ventilation, pending the results of the first blood gas analysis.*

Question 67

Zollinger-Ellison syndrome is associated with which Multiple Endocrine Neoplasia (MEN) syndrome?

Answer 67

MEN type I ## Footnote *MEN I is characterized by parathyroid tumors, pituitary tumors, and pancreatic tumors. Zollinger-Ellison Syndrome (gastrinoma) is the most common type of pancreatic endocrine tumor seen in MEN I.*

Question 68

What is the drug of choice for treating Primary biliary cirrhosis (a chronic liver disease characterized by autoimmune destruction of the intrahepatic bile ducts and cholestasis)

Answer 68

**Ursodeoxycholic acid**, which slows disease progression and relieves symptoms. Methotrexate and Colchicine have also been shown to be moderately beneficial. Cholestyramine forms a nonabsorbable complex with bile acids in the small intestine, reducing pruritis and hypercholesterolemia seen in PBC patients but it has no affect on the underlying condition or survival rates

Question 69

What organism causes amebic liver cysts?

Answer 69

Entamoeba histolytica *The primary infection is in the colon leading to bloody diarrhea; however, the ameba may be transported to the liver by portal circulation thus leading to an amebic liver abscess.* *Amebic liver abscesses are generally single and are located usually in the right lobe. An abscess on the superior surface of liver can cause a pleuritic-like type of pain and radiation to the shoulder.* *The diagnosis can be made by stool examination for trophozoites, serology, and liver imaging.*

Question 70

The following findings are consistent with what diagnosis? 1. Diarrhea 2. Hypokalemia resulting in leg cramps 3. Decreased amount of acid in the stomach 4. Dehydration 5. Abdominal pain and cramping 6. Weightloss 7. Facial flushing and redness

Answer 70

Vasoactive peptide adenoma (VIPoma) ## Footnote *VIPomas are cancerous tumors that affect cells in the pancreas that produce vasoactive intestinal peptide (VIP). The cause is not known. VIPomas are diagnosed most commonly at age 50 years or so. Women are more likely to be affected than men. High levels of VIP in the blood is diagnostic. A CT scan or MRI is ordered to determine the location of the tumor.*

Question 71

What X-linked recessive disorder commonly seen in African-American men is characterized by episodic hemolysis in response to oxidant drugs, infections, or fava beans?

Answer 71

Glucose-6-phosphate dehydrogenase (G6PD) deficiency ## Footnote *Heinz bodies are characteristically seen on the peripheral blood smear. G6PD is an enzyme involved in creating NADPH, a cofactor required to create glutathione and prevent the oxidation of hemoglobin. Without G6PD, hemoglobin becomes oxidized and denatures into Heinz bodies. The denatured hemoglobin disrupts red blood cell membranes and causes hemolysis.*

Question 72

All patients with acute cocaine toxicity and myocardial ischemia should be treated initially with supplemental oxygen and what?

Answer 72

Intravenous benzodiazepines *By reducing sympathetic outflow, benzodiazepines reduce anxiety and agitation, improve blood pressure and heart rate, and alleviate cardiovascular symptoms. Aspirin retards thrombus formation;nitrates and calcium channel blockers, being vasodilators, are beneficial for the cocaine-induced coronary artery vasoconstriction. Beta-blockers, however, should not be used in patients with cocaine-induced myocardial ischemia or infarction as their use can cause unopposed alpha adrenergic stimulation and worsen coronary vasoconstriction.*

Question 73

What are the 6 most common kinds of nephrotic syndrome?

Answer 73

1. Focal segmental glomerulosclerosis 2. Minimal change disease 3. Membranous nephropathy 4. Diabetes 5. Primary amyloidosis 6. IgA nephropathy ## Footnote *In no specific order.*

Question 74

What plasma measure has recently become a useful laboratory test to distinguish between CHF and other causes of dyspnea?

Answer 74

Plasma BNP *BNP \> 100pg/mL is diagnostic of CHF with a predictive accuracy of 83%. BNP is released from the cardiac ventricles in response to volume overload.*

Question 75

What is the most common cause of folic acid deficiency?

Answer 75

Nutritional (I.E. poor diet or alcoholism) ## Footnote *Folic acid deficiency can be caused by some drugs; these drugs can impair the absorption of folic acid (I.E. phenytoin) or antagonize its physiologic effects (I.E. methotrexate, trimethoprim).*

Question 76

Quinidine is used to treat what?

Answer 76

Atrial arrhythmias *Side effects include diarrhea, tinnitus, _QT prolongation_, torsades de pointes, hemolytic anemia and thrombocytopenia*

Question 77

What is the most sensitive and specific imaging study to detect gallstones?

Answer 77

Abdominal ultrasound ## Footnote *If the ultrasound is nondiagnostic or difficult to interpret and there is high clinical suspicion for common bile duct disease, endoscopic ultrasound/endoscopic retrograde cholangiopancreatography (ERCP) may be performed to better visualize the gallbladder and biliary tree.*

Question 78

What is a major cause of chronic diarrhea in HIV-infected patients with CD4 counts \< 180 cells/mm³?

Answer 78

Cryptosporidium parvum ## Footnote *A modified acid-fast stain showing oocysts in the stool is very suggestive of an infection with cryptosporidium parvum. This organism can cause severe diarrheal disease in both immunocompetent and immunocompromised individuals. HIV-infected patients with a more preserved CD4 count tend to have a self-limiting illness, whereas AIDS patients with CD4 counts \< 180 cells/mm3 tend to have a more persistent clinical course. Isospora belli is also suggested by the presence of acid-fast oocysts, but infections with Isospora belli are not as common as Cryptosporidium in the United States.*

Question 79

What should be high on the differential of an otherwise young, healthy patient who develops CHF?

Answer 79

Myocarditis *Viral infection, especially with Coxsackie B virus, is the most common cause.*

Question 80

When can the MMR vaccine be administered to to an HIV patient?

Answer 80

When CD4 count is \>200/micro-L and there is no history or evidence of an AIDS-defining illness

Question 81

Asymetrically elevated blood pressure in the right arm or the arms greater than legs is suggestive of what?

Answer 81

Coarctation of the aorta

Question 82

What segment of colon is most commonly involved in ischemic colitis?

Answer 82

The splenic flexure ## Footnote *This is because it is supplied by end arteries. The splenic flexure is a "watershed" line between the territory of the superior and inferior mesenteric arteries. There are two watershed zones in the colon: The splenic flexure, which is supplied by narrow terminal branches of the inferior mesenteric artery, and the recto-sigmoid junction, which is supplied by narrow terminal branches of the inferior mesenteric artery. These two watershed areas are most vulnerable to ischemia during systemic hypotension.*

Question 83

What criteria differentiates mild-moderate clostridium difficile colitis from severe clostridium difficile colitis?

Answer 83

_Mild-moderate:_ 1. WBC \< 15,000 2. Creatinine \< 1.5x baseline _Severe:_ 1. WBC _\>_ 15,000 2. Creatinine \> 1.5x baseline

Question 84

What renal manifestation of chronic hepatitis C is most common?

Answer 84

Membranoproliferative glomerulonephritis

Question 85

A delta wave is an upsloping just before the QRS complex that occurs in patients with what?

Answer 85

An accessory conduction pathway like in Wolf-Parkinson-White syndrome

Question 86

What is the likely diagnosis in a patient younger than 30 years old with unexplained chronic hepatitis?

Answer 86

Wilson's disease ## Footnote *The presence of low serum ceruloplasmin and increased urinary copper excretion or Kayser-Fleischer rings confirms the diagnosis.*

Question 87

Isolated systolic hypertension (ISH) is an important cause of hypertension in elderly patients that is caused by what?

Answer 87

Decreased elasticity of the arterial wall ## Footnote *ISH should always be treated due to its associateion with an increased risk for cardiovascular events. Initial treatment involves monotherapy with a low dose thiazide, an ACE inhibitor, or a long-acting calcium channel blocker*

Question 88

What are the 6 criteria used to establish the diagnosis of osteoarthritis?

Answer 88

1. Age \> 50 2. Crepitus 3. Bony enlargement 4. Bony tenderness 5. Lack of warmth 6. Minimal or no morning stiffness If patient meets 3 or more criteria, the specificity for OA is 69% and the sensitivity is 95%

Question 89

What is the test of choice for confirming the diagnosis of Zenker's diverticulum?

Answer 89

Contrast esophagram ## Footnote *This will clearly show the diverticulum.*

Question 90

Cochlear dysfunction is a side effect of what two immunosuppressants that are often used to treat testicular, ovarian, and bladder cancers?

Answer 90

Cisplatin and Carboplatin

Question 91

What disease is primary sclerosing cholangitis frequently associated with?

Answer 91

Ulcerative colitis

Question 92

How might increased production of stomach acid lead to malabsorption?

Answer 92

Inactivation of pancreatic enzymes ## Footnote *Malabsorption may occur in patients with Zollinger-Ellison syndrome.*

Question 93

What is the drug of choice for treating a patient with suspected aspiration pneumonia (recent stroke, history of unconciousness, heavy alcohol user, recent sedation)?

Answer 93

Clindamycin

Question 94

Which nephrotic syndrome has an association with obesity, heroin use, and HIV and accounts for \>50% of nephrotic syndromes in African Americans?

Answer 94

Focal Segmental Glomerulosclerosis

Question 95

What protein is defective in hereditary spherocytosis?

Answer 95

Spectrin *This is the protein that provides scaffolding for red blood cells.* *This is an autosomal dominant disorder.*

Question 96

Serum Alpha-fetoprotein (AFP) is elevated in patients with what kind of cancer?

Answer 96

Hepatocellular carcinoma

Question 97

What is the most frequent origin of the ectopic foci that cause atrial fibrillation?

Answer 97

The pulmonary veins *Cardiac tissue (myocardial sleeves) extend into the pulmonary veins and normally functions like a sphincter during atrial systole. This tissue has different electrical properties than the surrounding atrial myoctes and is prone to ectopic electrical foci and/or aberrant conduction which can initiate atrial fibrillation*

Question 98

What is the treatment of choice for Polymyalgia Rheumatica in the presence of symptoms of Temporal Arteritis?

Answer 98

Emergent High-dose Prednisone to prevent vision loss while a temporal artery biopsy is performed to confirm diagnosis of Temporal (Giant cell) Arteritis

Question 99

Multiple episodes of thrombosis in an older patient without a clear precipitating factor should raise concern for hypercoagulability due to what?

Answer 99

Primary malignancy *In a younger patient, it would be more suggestive of a genetic defect (I.E. Deficiencies in Protein C, Protein S, or Antithrombin III)*.

Question 100

What is the inheritance pattern of hereditary spherocytosis?

Answer 100

Autosomal dominant ## Footnote *It results from a disorder of spectrin, the protein that provides scaffolding for red blood cells.*

Question 101

Blood at the beginning of urination typically indicates a lesion where?

Answer 101

In the urethra ## Footnote *Such as in urethritis.*

Question 102

Mixed cryoglobulinemia is most commonly due to what?

Answer 102

Hepatitis C ## Footnote *It presents with immune complex deposition in small blood vessels, leading to endothelial injury, inflammation, and end-organ damage. The immune complexes are IgM antibodies (similar to rheumatoid factor) that form complexes with IgG and anti-hepatitis C virus antibodies, hepatitis C virus RNA, and complement. Low complement levels, increased rheumatoid factor, increased liver transaminases, serum cryoglobulins, and kidney/skin biopsy can confirm the diagnosis.*

Question 103

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

Answer 103

Cardiovascular disease ## Footnote *It accounts for approximately 50% of all deaths in this population. Cardiovascular disease is also the most common cause of death in renal transplant patients. Infection is also a common cause of death in dialysis patients, accounting for approximately 15-20% of deaths, and is most commonly related to vascular access (line sepsis).*

Question 104

What is the most important risk factor for bladder cancer?

Answer 104

Cigarette smoking ## Footnote *Other risk factors include occupational exposures (I.E. painters, metal workers), chronic cystitis, iatrogenic causes (I.E. Cyclophosphamide), and pelvic radiation exposure.*

Question 105

Metformin should not be given to a patient with what 3 conditions?

Answer 105

1. Renal failure 2. Hepatic failure 3. Sepsis

Question 106

What drugs are considered first line agents in uncomplicated hypertension?

Answer 106

Thiazide diuretics and beta-blockers because of their effect in reducing cardiovascular mortality and their cost effectiveness

Question 107

What diagnosis is suggested by mucopurulent urethral discharge, absent bacteriuria, and history of multiple sexual partners?

Answer 107

Chlamydial urethritis ## Footnote *Dysuria and urinary frequency can occur. Urinalysis reveals absent bacteriuria. Urine culture shows less than 100 colonies/mL. Gonococcal urethritis is less common than chlamydial urethritis. The urethral discharge in gonococcal urethritis is purulent (rather than mucopurulent), and gram stain usually reveals the causative organisms.*

Question 108

A prolonged QRS interval suggests what?

Answer 108

A bradyarrhythmia (typically bundle branch block) *Prolonged PR intervals are also often associated with bradyarrhythmias*

Question 109

Patient presents with ataxia, vomiting, occipital headache, gaze palsy, and facial weakness. There is no hemiparesis. What is the diagnosis?

Answer 109

Cerebellar hemorrhage *Early diagnosis is essential since urgent decompression may be life-saving. If left untreated, stupor or coma may ensue due to brainstem compression*

Question 110

Diastolic and continuous murmurs as well as loud systolic murmurs revealed on cardiac auscultation should always be investigated using what?

Answer 110

Transthoracic doppler echocardiography *Midsystolic soft murmurs (Grade I & II out of VI) in an asymptomatic young patient are usually benign and need no further work-up*

Question 111

What is characterized by a narrow QRS, progressive increase in PR interval until a ventricular beat is dropped, then the sequence is repeated?

Answer 111

Wenckebach or Mobitz type I heart block (A type of second-degree AV block) ## Footnote *It is a benign arrhythmia and is transient. Unless the patient is symptomatic, it requires no treatment.*

Question 112

If left untreated, Patients with hyperthyroidism become at risk for what?

Answer 112

Rapid bone loss *Direct effects of the thyroid hormones on the bone cells eventually lead to increased osteoclastic bone resorption*

Question 113

Acute epididymitis in older men is usually caused by what organisms?

Answer 113

Gram-negative rods (I.E. Escherichia coli) Acute epididymitis is characterized by fever, painful enlargement of the testes, and irritative voiding symptoms. It can be either sexually transmitted or non-sexually transmitted. Sexually transmitted acute epididymitis is more common in adults and is associated with urethritis, which causes pain at the tip of the penis and urethral discharge. Non-sexually transmitted acute epididymitis occurs in older persons and is usually associated with a urinary tract infection.

Question 114

An abdominal radiograph demonstrating air-fluid levels in the gallbladder or an ultrasound showing curvilinear gas shadowing in the gallbladder confirms what diagnosis?

Answer 114

Ephysematous cholecystitis ## Footnote *This is a form of acute cholecystitis that arises due to secondary infection of the gallbladder wall with gas-forming bacteria (I.E. clostridium, Escherichia, staphylococcus, streptococcus, pseudomonas, and klebsiella).*

Question 115

What renal side-effect can occur with high-dose parenteral acyclovir therapy?

Answer 115

Crystalluria with renal tubular obstruction ## Footnote *Nephrotoxicity is a well-known side effect of acyclovir therapy. Acyclovir is poorly soluble in urine and easily precipitates in renal tubules causing obstruction and acute renal failure. Crystalluria with renal tubular obstruction usually occurs during administration of large parenteral doses of acyclovir; inadequate hydration is a predisposing factor. Oliguria with elevated creatinine and BUN are typical for acute renal failure.*

Question 116

What is considered the single most important test to assess the function of the liver?

Answer 116

Prothrombin time (PT) ## Footnote *All clotting factors (except for factor VIII) are synthesized in the liver. When the liver is unable to create sufficient amounts of clotting factors, the PT is prolonged.*

Question 117

What must be monitored closely in patients taking aminoglycosides?

Answer 117

Renal function ## Footnote *Aminoglycosides are antibiotics used to treat serious gram-negative infections. They are potentially nephrotoxic.*

Question 118

What is the best diagnostic test for diverticulitis in the acute setting?

Answer 118

Abdominal computed tomography (CT) *This helps differentiate it from other causes of abdominal pain (I.E. Colon cancer and kidney infection)*.

Question 119

Hypertension, hypernatremia, hypokalemia, metabolic alkalosis, low renin levels, and high aldosterone levels is characteristic of what condition?

Answer 119

Conn's Syndrome (Primary hyperaldosteronism)

Question 120

Fever, cough, coryza, conjunctivitis, and a rash starting on face and spreading to body is typical of what?

Answer 120

Measles *Koplick spots are suggestive*

Question 121

What are the major side effects of azathioprine?

Answer 121

1. diarrhea 2. Leukopenia 3. Hepatotoxicity ## Footnote *The side effects are dose-related. Azothioprine is a purine analog that is enzymatically converted to 6-mercaptopurine. It acts primarily by inhibiting purine synthesis.*

Question 122

What pharmacological agents should be avoided in variant (Prinzmetal's) angina?

Answer 122

non-selective Beta-blockers and aspirin *Nonselective beta-blockers such as propranolol should be avoided because Beta-2 receptor inhibition can lead to worsened coronary vasospasm. Aspirin should be avoided because it causes prostacyclin inhibition, which can promote vasospasm*

Question 123

The most common site of hypertensive hemorrhage is where?

Answer 123

The Putamen *Accounts for 35% of hypertensive hemorrhages. The internal capsule that lies adjacent to the putamen is almost always involved, thereby leading to hemiparesis. The eyes deviate away from the paralytic side*

Question 124

What is the initial treatment of both acute and chronic anal fissures?

Answer 124

1. Dietary modification (I.E. High-fiber diet and large amounts of fluids) 2. Stool softener 3. Local anesthetic ## Footnote *The local anesthetic relieves the local spasm, and the stool softener creates soft, bulky, atraumatic stools that disrupt the vicious cycle of constipation and fissure development. This treatment also allows the fissure to heal in approximately 50% of patients.*

Question 125

What is the diagnostic procedure of choice for detecting nephrolithiasis

Answer 125

CT scan of the abdomen because it can differentiate between calcium stones (radioopaque) and uric acid stones (radiolucent)

Question 126

The redistribution of coronary blood flow to 'non-diseased' segments induced by dipyridamole is called what?

Answer 126

Coronary steal phenomenon

Question 127

What are the three major treatment options of patients with Grave's Disease?

Answer 127

1. Radioactive iodine ablation: Preferred modality of tx in USA 2. Antithyroid drug therapy 3. Thyroidectomy

Question 128

How is the diagnosis of peptic ulcer disease made?

Answer 128

Upper endoscopy

Question 129

Lynch syndrome II (hereditary non-polyposis colorectal cancer type II) is distinctly associated with a high risk of extracolonic tumors, the most common of which is what?

Answer 129

Endometrial carcinoma ## Footnote *This develops in up to 43% of females in affected families.*

Question 130

Symptoms of alopecia, skin lesions, abnormal taste, and impaired wound healing are suggestive of what vitamin/nutrient deficiency?

Answer 130

Zinc deficiency ## Footnote *Zinc deficiency may result from chronic total parenteral nutrition or malabsorption. Zinc deficiency in children may also cause growth retardation. Zinc is an essential mineral, and is found in animal protein, whole grains, beans and nuts. It is digested primarily in the jejunum.*

Question 131

Nodular glomerulosclerosis (with Kimmelstiel-Wilson nodules) is pathognomonic for what condition?

Answer 131

Diabetic nephropathy ## Footnote *The pathologic hallmark is nodular glomerulosclerosis but diffuse glomerulosclerosis is more common.*

Question 132

75-90% of kidney stones are composed of what?

Answer 132

Calcium oxalate ## Footnote *Calcium oxalate crystals are envelope-shaped, and can be seen on microscopic examination of urine. Small bowel disease, surgical resection, or chronic diarrhea can lead to malabsorption of fatty acids and bile salts; this predisposes to the formation of calcium oxalate stones. Fat malabsorption leads to the increased absorption of oxalic acid because the unabsorbed fatty acids chelate calcium, making oxalic acid free for absorption.*

Question 133

Unilateral radicular pain in a dermatomal distribution is the classic presentation of what?

Answer 133

Disk prolapse ## Footnote *A large midline disk herniation can cause nerve root injury known as cauda equina syndrome, a condition characterized by bladder atony with overflow incontinence, bilateral sciatica, saddle anesthesia and loss of anal sphincter tone.*

Question 134

What can be done to minimize the chance of causing contrast-induced nephropathy in a patient recieving contrast for imaging purposes?

Answer 134

1. Use non-ionic contrast agent 2. Adequate intravenous hydration 3. Acetylcysteine ## Footnote *These all decrease the incidence of nephropathy.*

Question 135

The left anterior decsending coronary artery (LAD) usually supplies what?

Answer 135

The anterior wall of the left ventricle as well as the anterior 2/3rds of the septum *Occlusion most commonly causes ST-segment elevation in V1-V4*

Question 136

What is the next step following detection of a painless, hard testicular mass with a ultrasound that is suggestive of cancer?

Answer 136

Radical Orchiectomy: Removal of testis + associated cord

Question 137

What is the typical presentation for vertebral osteomyelitis?

Answer 137

1. Back pain accompanied by low-grade fever and elevated ESR. 2. Physical exam may demonstrate local tenderness on percussion over the affected vertebrae and paravertebral muscular spasm. *High-grade fever and chills are uncommon*

Question 138

What is the diagnosis? Symptoms: Hypertension, headaches, epistaxis, blurred vision, and possibly heart failure due to severe hypertension ECG: indicates LVH Chest xray: shows notching of 3rd-8th ribs

Answer 138

Coarctation of the aorta (Check bilateral blood pressure)

Question 139

What is the most effective lifestyle changes in reducing BP?

Answer 139

1. Weight loss (in obese patients): 5-20mmHg reduction 2. Physical activity: 4-9mmHg reduction 3. Salt restriction: 2-8mmHg reduction 4. Reduction of alcohol intake: 2-4mmHg reduction

Question 140

What diagnosis can be confirmed with the characteristic biopsy finding of dark brown discoloration of the colon with lymph follicles shining through as pale patches?

Answer 140

Laxative abuse *This dark brown discoloration is known as melanosis coli.* *Melanosis coli is not characteristic for celiac disease, infectious diarrhea, or non-hodgkin's lymphoma*

Question 141

What is the best initial test of choice to assess for hydronephrosis?

Answer 141

Abdominal ultrasound

Question 142

How is Alpha-1 antitrypsin (A1AT) deficiency diagnosed?

Answer 142

A1AT is established by measurement of the serum A1AT level, followed by confirmatory genetic testing ## Footnote *A1AT is coded for by a single, highly pleomorphic gene on chromosome 14.*

Question 143

What cardiac abnormality produces a fixed split S2?

Answer 143

Atrial septal defect

Question 144

Acute transplant rejection is best treated with what?

Answer 144

Intravenous steroids ## Footnote *Biopsy of the transplant will show heavy lymphocyte infiltration and vascular involvement with swelling of the intima.*

Question 145

What are the criteria that change the first step in management of a patient presenting with gastroesophageal reflux (GERD)?

Answer 145

Men age \> 50 years old with Symptoms for \> 5 years or Cancer risk factors or Alarm symptoms (melena, persistent vomiting, hematemesis, weight loss, anemia, dysphagia/odynophagia) *If the patient meets any of these criteria, an endoscopy should be performed. In the absence of any of these criteria, a once daily proton pump inhibitor can be tried for 2 months.*

Question 146

This is an autoimmune blistering disorder marked by pruritis, tense bullae, and urticarial plaques. The classic direct immunoflourescence finding is of IgG and C3 distributed linearly along the basement membrane zone.

Answer 146

Bullous pemphigoid

Question 147

What should you always suspect in a female with multiple neurologic presentations that are interspaced between time periods?

Answer 147

Multiple Sclerosis

Question 148

What is the most common cause of death in patients with acute MI?

Answer 148

Complex ventricular arrhythmia *Acute ischemia creates heterogeneity of conduction in the myocardium. Areas of partial block of conduction are frequently formed that predispose the patient to reentrant arrhythmias. Ventricular fibrillation is a typical example of reentrant arrhythmia. Decline in mortality of patients hopitalized with acute coronary syndromes is largely attributable to the effective detection and treatment of reentrant ventricular arrhythmias.*

Question 149

Sodium Bicarbonate, Beta agonists, and insulin + glucose all have what effect on K⁺?

Answer 149

They decrease the extracellular concentration of potassium by driving the potassium into the cell.

Question 150

In the management of blunt abdominal trauma in a hemodynamically unstable patient, what should follow an inconclusive focused assessment with sonography for trauma (FAST) examination?

Answer 150

Diagnostic peritoneal lavage (DPL) ## Footnote *If aspiration of 10 mL of peritoneal flluid shows blood, intraperitoneal injury is likely. If no gross blood is obtained, peritoneal cavity lavage with normal saline is performed and the effluent is sent to the laboratory for analysis (red blood cell count). A positive DPL should be followed by an exploratory laparotomy. A negative DPL should be followed by stabilization, and in the absence of signs of extra-abdominal hemorrhage, CT of the abdomen.*

Question 151

What is the most important cause of Torsades de Pointes?

Answer 151

Hypomagnesemia

Question 152

Asymmetrically elevated blood pressure in the left arm is suggestive of what?

Answer 152

Subclavian artery stenosis

Question 153

What is the ideal antibiotic regimen for hospitalized patients who develop meningitis, especially after neurosurgery?

Answer 153

IV Ceftazidime + Vancomycin ## Footnote *These drugs cover pseudomonas and Staph Aureus respectively*

Question 154

Shingles is due to reactivation of varicella zoster virus from where in the body?

Answer 154

Dorsal root ganglia

Question 155

Severe hypertension with cerebral edema & non-localizing neurologic symptoms & signs is called what?

Answer 155

Hypertensive encephalopathy

Question 156

What diagnosis should be suspected in patients presenting with sudden onset severe epigastric pain that spreads over the entire abdomen?

Answer 156

Chemical peritonitis due to a perforated peptic ulcer ## Footnote *Upright chest and/or abdominal radiographs typically reveal free air under the diaphram.*

Question 157

What empiric antibiotic therapy should be started for a patient with spontaneous bacterial peritonitis while the results of an ascites fluid culture are pending?

Answer 157

3rd generation cephalosporin

Question 158

Hematuria at the end of voiding typically suggests a lesion where?

Answer 158

Prostate or bladder

Question 159

What is the most effective measure for decreasing the risk of urinary tract infections in patients requiring bladder catheterization?

Answer 159

Intermittent catheterization

Question 160

How does pain with meals differ between duodenal ulcers and gastric ulcers?

Answer 160

1. Duodenal ulcers usually improve with food 2. Gastric ulcers tend to worsen with food ## Footnote *Melena and abdominal pain are most likely due to peptic ulcer disease. The diagnosis is made by upper endoscopy.*

Question 161

Ascending aortic aneurysms are most often due to what?

Answer 161

Cystic medial necrosis or connective tissue disorders *The #1 risk factor for aortic dissection is still hypertension*

Question 162

What is the primary medical therapy for aortic regurgitation?

Answer 162

Afterload reduction with vasodilators like nifedipine or ACE inhibitors *For aortic regurgitation so severe as to cause symptoms, valve replacement is generally recommended.*

Question 163

What is the drug of choice for treating Trigeminal Neuralgia?

Answer 163

Carbamazepine

Question 164

What are the 4 steps in the stepwise approach to treating ascites?

Answer 164

1. Sodium and water restriction 2. Spironolactone 3. Loop diuretic (not more than 1 L/day of diuresis) 4. Frequent abdominal paracentesis (2-4 L/day as long as the renal function is okay) ## Footnote *The treatment of ascites starts with Na⁺ and water restriction (2 L/day). Diuretic therapy, if needed is typically started with spironolactone. When the maximal dose of spironolactone fails to improve the patient's status, giving a loop diuretic (I.E. Furosemide) is recommended. Aggressive diuresis (\> 1 L/day) is not recommended due to the risk of hepato-renal syndrome.*

Question 165

What are some metabolic side effects of thiazide diuretics?

Answer 165

1. Hyperglycemia 2. Increased LDL cholesterol 3. Plasma triglycerides

Question 166

What is the earliest renal abnormality seen in diabetic nephropathy?

Answer 166

Glomerular hyperfiltration ## Footnote *It is also the major pathophysiologic mechanism of glomerular injury in these patients. It creates intraglomerular hypertension leading to progressive glomerular damage and renal function loss. The effectiveness of Angiotensin converting enzyme (ACE) inhibitors in diabetic nephropathy is related to their ability to reduce intraglomerular hypertension and, thereby, decrease glomerular damage. Thickening of the glomerular basement membrane is the first change that can be quantitated. This is followed by mesangial expansion. Nodular sclerosis is superimposed later and is specific for diabetic nephropathy.*

Question 167

What kind of shock is characterized by: 1. Elevated right atrial pressure 2. Elevated capillary wedge pressure 3. Elevated systemic resistance 4. Decreased mixed venous oxygen saturation 5. Markedly reduced cardiac index (pump function)

Answer 167

Cardiogenic shock *Once pump failure occurs in cardiogenic shock, blood backs into the lungs, causing increased pulmonary capillary wedge pressure. Systemic vascular resistance is typically increased to maintain adequate tissue perfusion pressure. The lower tissue perfusion signals the tissue to extract more oxygen from the blood, which decreases mixed venous oxygen saturation. All of this manifests clinically as depressed mental status, dyspnea, decreased urinary output, and cool extremities*

Question 168

How do you differentiate hemorrhages from infarcts on CT?

Answer 168

1. Hemorrhages are seen as hyperdense areas 2. Infarcts are seen as hypodense parenchymal areas

Question 169

What are the drugs of choice for in-patient treatment of community-acquired pneumonia?

Answer 169

Newer antipneumococcal quinolones, like levofloxacin or mosifloxacin

Question 170

Pulsus parvus and pulsus tardus are classically observed in patients with what?

Answer 170

Aortic stenosis *Pulsus parvus and tardus refers to a carotid pulse that is slow and late*

Question 171

Nonsteroidal anti-inflammatory drugs are a common cause of what kind of anemia?

Answer 171

Iron deficiency anemia ## Footnote *This often occurs through chronic blood loss from the gastrointestinal tract.*

Question 172

The presence of bilirubin in the urine is indicative of what?

Answer 172

Conjugated hyperbilirubinemia ## Footnote *Unconjugated bilirubin is highly insoluble in water and is tightly bound to albumin. When bound, this unconjugated bilirubin cannot be filtered by the glomerulus and is therefore not excreted in the urine. Dubin-Johnson syndrome and Rotor syndrome are inheritable forms of conjugated hyperbilirubinemia.*

Question 173

Hepatic adenomas are uncommon benign epithelial tumors of the liver that usually arise as a solitary mass in the right hepatic lobe. The are predominantly found in what patient population?

Answer 173

Young and middle-aged women who have a lengthy history of oral contraceptive usage *Hepatic adenomas may also be seen in association with anabolic androgen use, glycogen storage disease, pregnancy, and diabetes*

Question 174

What is the neuromuscular blocking agent of choice in a patient with both renal and liver dysfunction?

Answer 174

Atracurium

Question 175

What test should be done for a patient with symptoms suggestive of Zollinger-Ellison syndrome after an inconclusive serum gastrin level?

Answer 175

Secretin stimulation test ## Footnote *Secretin stimulates the release of gastrin by gastrinoma cells. Normal gastric G cells are inhibited by secretin; thus, the administration of secretin should not cause a rise in serum gastrin concentrations in patients with other causes of hypergastrinemia. The calcium infusion study is usually reserved for patients with gastric acid hypersecretion who are strongly suspected of having gastrinoma despite a negative secretin test. Calcium infusion can lead to an increase in serum gastrin levels in patients with gastrinoma.*

Question 176

What is the treatment of choice for pseudotumor cerebri?

Answer 176

Acetazolamide

Question 177

Electrical alternans is when the amplitudes of the QRS complexes vary from beat to beat. It is fairly specific for what?

Answer 177

Pericardial effusion

Question 178

Unexplained hemolytic anemia and thrombocytopenia in a patient with renal failure and neurologic symptoms should raise strong suspicions for what diagnosis?

Answer 178

Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) ## Footnote *The presence of fragmented cells in the peripheral smear suggests microangiopathic hemolytic anemia (MAHA), a characteristic finding in TTP-HUS.*

Question 179

What is more common in young females and presents as intermittent episodes of chest pain and dysphagia?

Answer 179

Diffuse esophageal spasm ## Footnote *Barium swallow may reveal a "corkscrew" esophagus. The treatment is supportive with antispasmodics, dietary modulation and psychiatric counseling.*

Question 180

Which antihypertensive can cause peripheral edema?

Answer 180

Dihydropyridine Ca-channel antagonists like amlodipine *This is due to them dilating peripheral blood vessels and not due to an allergic reaction.*

Question 181

Why doesnt the Pneumococcal vaccine produce T-Cell immunity?

Answer 181

The vaccine contains capsular polysaccharides of the 23 most prevalent types of pneumococcus. Whereas peptides get presented to T-cells by macrophages and B-cells, polysaccharides cannot be presented to T-cells. Thus, polysaccharide vaccines yield a B-cell only (T-cell independent) response.

Question 182

Lidocaine is used to treat what?

Answer 182

Ventricular arrhythmias *High doses can cause confusion, seizures and respiratory depression*.

Question 183

Diminshed heart sounds on auscultation and a difficult to palpate point of maximal impulse is indicative of what?

Answer 183

Pericardial effusion *Most commonly idiopathic (thought to be due to a viral illness) but can also be due to malignancy, post- MI, uremia, autoimmune diseases, and hypothyroidism. Large pericardial effusions typically appear on chest x-ray as an enlarged and globular-appearing cardiac shadow.*

Question 184

Panacinar emphysema and cirrhosis are suggestive of what condition?

Answer 184

Alpha-1 Antitrypsin (A1AT) deficiency ## Footnote *This is a serum protein that is primarily produced in the liver and inhibits several different proteolytic enzymes. It is also an acute-phase reactant that plays a significant role in inflammatory states.*

Question 185

What is the most common cause of constrictive pericarditis in developing countries and endemic areas such as Africa, India, and China?

Answer 185

Tuberculosis

Question 186

What is the treatment for a pyogenic liver abscess?

Answer 186

Intravenous broad-spectrum antibiotic (ceftriaxone), metronidazole, and drainage

Question 187

What is the major cause of anemia in patients with end stage renal disease?

Answer 187

Deficiency of erythropoietin ## Footnote *This is a normocytic, normochromic anemia. The treatment of choice is recombinant erythropoietin, which is started if the hemoglobin is*

Question 188

Patients with severe aortic stenosis can have anginal chest pain due to what?

Answer 188

Increased myocardial oxygen demand

Question 189

Patient presents with deep coma and paraplegia that developed within a few minutes. The pupils are pinpoint and reactive to light. There is decerebrate rigidity. There are no horizontal eye movements. What is the diagnosis?

Answer 189

Pontine hemorrhage *Accounts for 5-12% of hypertensive intraparenchymal hemorrhages*

Question 190

What is the usual cause of myoglobinuria?

Answer 190

Rhabdomyolysis which frequently leads to acute renal failure

Question 191

What are the main reasons for the increased incidence of orthostatic hypotension in the elderly?

Answer 191

Progressively decreasing baroreceptor sensitivity and defects in the myocardial response to this reflex

Question 192

What treatments are available for achalasia?

Answer 192

1. Botulinum toxin injection into the lower esophageal sphincter (LES) 2. Nitrates or calcium channel blockers 3. Pneumatic dilatation 4. Surgical myotomy ## Footnote *Nitrates and calcium channel blockers relax the smooth muscles of the lower esophageal sphincter and have been used as medical therapy with variable success rates.*

Question 193

What is the inheritance pattern of Wilson's disease?

Answer 193

Autosomal recessive ## Footnote *Most often identified in younger individuals aged 5-40 years. The genetic mutations associated with Wilson's disease hinder copper metabolism by reducing the formation and secretion of ceruloplasmin and by decreasing the secretion of copper into the biliary system.*

Question 194

Adenomatous polyps can be divided into 3 histological types with different rates of malignant transformation. What is the order in which they fall from lowest risk to highest risk?

Answer 194

1. Tubular adenoma 2. Tubulovillous adenoma: As the villous component increases, the risk of malignancy increases 3. Villous adenomas: These are most commonly sessile and 3 times more likely than tubular adenomas for malignant transformation ## Footnote *Hyperplastic polyps are the most common non-neoplastic polyps in the colon. These arise from hyperplastic mucosal proliferation.*

Question 195

What is the major toxicity of mycophenolate?

Answer 195

Bone marrow suppression ## Footnote *Mycophenolate is a reversible inhibitor of inosine monophosphate dehydrogenase (IMPDH), which is the rate-limiting enzyme in de novo purine synthesis.*

Question 196

The following findings are consistent with what diagnosis? 1. Diabetes mellitus 2. Erectile dysfunction 3. Skin pigmentation 4. Arthropathy 5. Increased risk of cirrhosis and hepatocellular carcinoma

Answer 196

Hemochromatosis ## Footnote *Bilirubin and alkaline phosphatase levels are usually normal or mildly elevated without clinically obvious jaundice.*

Question 197

What diagnosis should be suspected for a patient who presents with the following? 1. Cirrhosis 2. Ascites 3. Low-grade fever 4. Abdominal discomfort 5. Altered mental status

Answer 197

Spontaneous bacterial peritonitis (SBP) ## Footnote *Ascitic fluid with polymorphonuclear leukocytes _\>_250/uL and positive peritoneal fluid culture confirm the diagnosis. The serum-ascites albumin gradient (SAAG) is the serum albumin minus ascites albumin. SAAG _\>_ 1.1g/dL indicates portal hypertension as the cause of ascites and makes SBP more likely.*

Question 198

In patients with dysphagia where the differential diagnosis is broad, what diagnostic test is usually performed first?

Answer 198

Barium esophagram *Upper endoscopy can be performed next, if the barium esophagram is inconclusive or negative*

Question 199

When the suspicion for DVT is moderate to high based on the history and physical exam, what is the next step?

Answer 199

Compression ultrasonography. *The decision to anticoagulate is not made based on the history and physical exam alone, but rather the results of non-invasive testing. If a DVT is detected, anitcoagulation with Heparin is initiated.*

Question 200

What kind of shock is characterized by: 1. Increased cardiac index (pump function) 2. Increased mixed venous oxygen saturation 3. Normal to decreased right atrial pressure 4. Normal to decreased pulmonary capillary wedge pressure 5. Decreased systemic vascular resistance

Answer 200

Septic shock *Peripheral vasodilation usually causes less blood to return to the heart*

Question 201

Unilateral eye pain, redness, and a dilated pupil with poor light response is indicative of what?

Answer 201

Acute angle closure glaucoma

Question 202

What is the inheritance of hereditary hemochromatosis?

Answer 202

Autosomal recessive ## Footnote *It occurs due to a mutated human hemochromatosis protein (HFE) gene that leads to increased intestinal iron absorption.*

Question 203

What is the most consistent reversible risk factor for pancreatic cancer?

Answer 203

Cigarette smoking

Question 204

Sore throat, fever, and pain with swallowing due to the formation of vesicles on the tonsils and soft palate caused by the Coxackie A virus is called what?

Answer 204

Herpangina (typically occurs in children)

Question 205

Descending aortic aneurysms are most often due to what?

Answer 205

Atherosclerosis ## Footnote *Risk factors include hypertension, hypercholesterolemia, and smoking.*

Question 206

Total hematuria reflects damage where?

Answer 206

Kidney or ureters

Question 207

What is required to diagnose atherosclerosis of the mesenteric arteries (causing abdominal angina)?

Answer 207

Angiography or a doppler ultrasound

Question 208

What is the treatment for an acute exacerbation of COPD?

Answer 208

Ipratropium + Albuterol nebulizer + systemic steroids. The most commonly used parenteral steroid is methylprednisolone.

Question 209

Which drug classes confer a survival benefit in CHF?

Answer 209

1. ACE inhibitors 2. ARBs 3. Beta-blockers 4. Spironolactone *Digoxin and Furosemide can reduce CHF symptoms and hopitalizations but they do not improve survival*

Question 210

Neuromuscular irritability, perioral tingling/numbness, muscle cramps, tetany, carpopedal spasms, seizures, and QT prolongation are all signs of what?

Answer 210

Hypocalcemia

Question 211

A 1-time DEXA screening for osteoarthritis is recommended for women over what age?

Answer 211

\>65 years of age

Question 212

What drugs are considered first line agents in hypertensive patients with diabetes, CHF, myocardial infarction, or chronic kidney disease?

Answer 212

ACE inhibitors because beta-blockers and thiazides may exacerbate hyperglycemia.

Question 213

How does serum albumin affect serum calcium?

Answer 213

40% of circulating serum calcium is bound to proteins. Albumin is responsible for 90% of protein binding of the serum calcium. Therefore, decreased albumin levels will be associated with decreased total serum calcium

Question 214

What condition is characterized by a defect in hepatic storage of conjugated bilirubin and leakage into the plasma, resulting in chronic and mild hyperbilirubinemia of both the unconjugated and conjugated forms without any suggestion of hemolysis?

Answer 214

Rotor syndrome ## Footnote *Liver function tests are normal. Pigmented granules are not seen in the hepatocytes of individuals with Rotor syndrome (Whereas Black liver is seen in Dubin-Johnson Syndrome).*

Question 215

What are the 6 most common causes of nephritic syndrome?

Answer 215

1. IgA nephropathy 2. Lupus nephritis 3. Thin basement membrane disease 4. Membranoproliferative glomerulonephritis 5. Rapidly progressive glomerulonephritis 6. Post-streptococcal glomerulonephritis ## Footnote *In no particular order.*

Question 216

What should always be considered in a young black male who presents with painless hematuria?

Answer 216

Sickle cell trait

Question 217

What is the gold standard for diagnosis of Wilson's disease?

Answer 217

Liver biopsy ## Footnote *Liver biopsy that demonstrates a quantitative hepatic copper level \>250 mcg/gram dry weight. More commonly, diagnosis is confirmed by the presence of low serum ceruloplasmin (particularly \<20mg/dL) in conjunction with increased urinary copper excretion or Kayser-Fleischer rings.*

Question 218

What is a well-known complication of giant cell (temporal) arteritis?

Answer 218

Aortic aneurysm due to involvement of the branches of the aorta *For this reason, patients should be followed with serial chest x-rays.*

Question 219

1. First-degree heart block is characterized by what? 2. What is the treatment?

Answer 219

1. A prolonged constant PR interval (\>0.2 seconds) 2. It is a completely benign arrhythmia that requires no treatment

Question 220

Sclerosing cholangitis, uveitis, erythema nodosum, and spondyloarthropathy are all associated with what condition?

Answer 220

Ulcerative colitis (UC) ## Footnote *These are all extraintestinal manifestations of UC. Severe complications include toxic megacolon and colon cancer. Routine surveillance with yearly colonoscopies is recommended for patients with UC beginning 8-10 years after diagnosis for prevention and/or early detection of colon cancer.*

Question 221

What diagnosis is characterized by a barium swallow that reveals an area of symmetric, circumferential narrowing affecting the distal esophagus of a patient with a history of gastroesophageal reflux?

Answer 221

Peptic stricture ## Footnote *Asymmetric narrowing of the esophageal lumen would be more concerning for adenocarcinoma.*

Question 222

What is the treatment of choice for Polymyalgia Rheumatica when it is not associated with giant cell arteritis?

Answer 222

Low-dose prednisone

Question 223

What condition is characterized by a positive hydrogen breath test, positive stool test for reducing substances, low stool pH and an increased stool osmotic gap?

Answer 223

Lactose intolerance ## Footnote *Currently, the lactose hydrogen breath test has largely replaced the lactose tolerance test. Lactase is a brush border enzyme that hydrolyzes lactose. Its concentration declines steadily as one ages into adulthood, especially in people of non-European ancestry. Lactose intolerance is most commonly seen in Asian-Americans (90%). Patients typically manifest with osmotic diarrhea, abdominal cramps, bloating and flatulence after ingestion of milk products. The stool pH is acidic in lactase deficiency due to the fermentation products.*

Question 224

What is the first step in the treatment of acute variceal bleeding?

Answer 224

Establish vascular access with two large bore intravenous needles or a central line.

Question 225

The following findings are consistent with what diagnosis? 1. Parathyroid adenoma 2. Pituitary tumors 3. Enteropancreatic tumors

Answer 225

Multiple Endocrine Neoplasia (MEN) type I ## Footnote *Parathyroid adenoma (\>90%), pituitary tumors (10-20%), enteropancreatic tumors (60-70%).*

Question 226

Asymptomatic patients with carotid artery stenosis of 60 to 99% are considered to have a proven indication for what intervention? *Men with lesions greater than 80% benefit the most*

Answer 226

**Carotid endarterectomy** (CEA) ***Carotid angioplasty with stenting** (CAS) is an alternative for patients with high surgical risk, poor 5-year predicted survival, or a lesion not amenable to surgery.* ***ASA + Statin** is the indicated therapy in patients with lesions less than 50%*

Question 227

What is the preferred diagnostic tool of aortic dissection?

Answer 227

Transesophageal echocardiography *The sensitivity and specificity of the MRI, CT, and transesophageal echocardiography in diagnosing aortic dissection exceeds 90%. The transesophageal echocardiography is usually preferred to an MRI because the latter is time-consuming*.

Question 228

"Eggshell" calcification of a hepatic cyst on CT scan is highly suggestive of what diagnosis?

Answer 228

Hydatid cyst ## Footnote *Hydatid cysts are caused by Echinococcus granulosus/ Humans contract the infection from the close and intimate contacts with dogs, which are the definitive host in the life cycle of E. Granulosis. it can cause a unilocular cystic lesion in any organs including liver, lung, muscle, and bones.*

Question 229

What is the treatment for Granulomatosis with polyangiitis (Wegener's granulomatosis)?

Answer 229

A combination of cyclophosphamide and steroids

Question 230

A tea and toast type of diet is associated with what vitamin/nutrient deficiency?

Answer 230

Folic acid deficiency ## Footnote *Folic acid is heat sensitive, so cooked foods are typically lacking. In the setting of dietary deficiency, folic acid stores can become depleted within 4-5 months, leading to decreased red blood cell production and macrocytic anemia.*

Question 231

The following findings are consistent with what diagnosis? 1. Necrotizing dermatitis 2. Weightloss 3. Anemia 4. Persistent hyperglycemia

Answer 231

Glucagonoma

Question 232

What treatment is urgently indicated in a patient with hyperkalemia who develops significant Electrocardiogram (ECG) changes?

Answer 232

Calcium gluconate ## Footnote *The patient should immediately be given intravenous calcium gluconate, which acts within minutes to antagonize the effects of hyperkalemia on the cell membranes of the heart. The effects of calcium gluconate are short-lived and further treatment with agents such as insulin and/or sodium polystyrene sulfonate will eventually be necessary as well to reduce the serum concentration of potassium.*

Question 233

What is the first treatment of choice for a patient with symptomatic (but hemodynamically stable) sinus bradycardia?

Answer 233

Intravenous atropine * Atropine provides an immediate increase in the heart rate by decreasing vagal input.* * Transcutaneous pacing is the next step after atropine, as it provides a sustained increase in heart rate. At that point, the identification and reversal of the underlying etiology of the sinus bradycardia is essential. Permanent pacemakers may be required in those individuals with chronic symptomatic sinus bradycardia*

Question 234

What is the management of a patient with suspected Clostridium difficile colitis?

Answer 234

1. Stool studies 2. Oral metronidazole ## Footnote *Severe colitis usually requires oral vancomycin with or without IV metronidazole or a possible switch to intracolonic vancomycin.*

Question 235

What is the preferred first step in treating a patient with hemodynamically stable ventricular tachycardia?

Answer 235

Intravenous Amiodarone is usually preferred over other antiarrhythmics

Question 236

What does a highly elevated creatine phosphokinase indicate?

Answer 236

Muscle injury ## Footnote *CPK levels should be checked in any patient on a statin who presents with myalgias. If highly elevated, the first step is to discontinue the statin. Muscle injury due to statins can progress to rhabdomyolysis with renal failure*

Question 237

How long must a patient be on Aspirin and Clopidogrel following bare metal stent or drug eluting stent placement

Answer 237

Bare metal stent: 30 days Drug eluting stent: 1 year *This has been shown to help prevent subacute stent thrombosis.*

Question 238

Vasospasm is the major cause of morbidity and mortality in patients with subarachnoid hemorrhage. What drug class is used to prevent vasospasm in patients with subarachnoid hemorrhage?

Answer 238

Calcium channel blockers (i.e. Nimodipine)

Question 239

All patients with chronic liver disease should be immunized against what?

Answer 239

Hepatitis A and Hepatitis B ## Footnote *Vaccinations should be administered unless the patient is already immune.*

Question 240

What is the pathology of angioedema?

Answer 240

C1 esterase inhibitor deficiency, dysfunction, or destruction. A defect or deficiency of C1 inhibitor leads to elecated levels of the edema-producing factors of C2b and bradykinin. *The most common cause of acquired isolated angioedema is ACE inhibitor use.*

Question 241

What is the treatment of choice for Actinomycosis

Answer 241

High-dose penicillin for 6-12 weeks

Question 242

What is the next step in management of pyelonephritis that has not improved after 48-72 hours of antibiotic therapy?

Answer 242

Ultrasound or computed tomography (CT) to search for any underlying pathologies or complications.

Question 243

What is the most common cause of nephrotic syndrome in patients with Hodgkin's lymphoma?

Answer 243

Minimal change disease (lymphocyte dysregulation and cytokine production may play a role)

Question 244

What antihypertensive is used to treat acute heart failure and what antihypertensive is contraindicated?

Answer 244

1. **ACE inhibitors** reduce afterload and are used to treat acute heart failure 2. **Beta-blockers** are contraindicated because they decrease myocardial contractility and exacerbate the already decreased ejection fraction

Question 245

What is the most common etiology of a mononeuropathy?

Answer 245

Vascular

Question 246

Nagging epigastric pain that is worse at night, food intolerance, weight loss, and enlarged nontender gallbladder, and icterus suggestive of biliary obstruction are findings suggestive of what diagnosis?

Answer 246

Pancreatic cancer ## Footnote *Most (60-70%) of pancreatic cancers originate in the head of the pancreas.*

Question 247

A systolic ejection-type murmur along the left sternal border that has a strong apical impulse and is worsened (made louder) by valsalva or standing is indicative of what?

Answer 247

Hypertrophic cardiomyopathy

Question 248

Where do anal fissures most often occur?

Answer 248

Posterior or anterior anal verge

Question 249

Jugular venous distension on physical exam and right bundle branch block on ECG in the setting of hypotension are strongly indicative of what?

Answer 249

Massive pulmonary embolism *Jugular venous distension and right bundle branch block are indicative of right heart strain and in the setting of hypotension, the diagnosis of massive PE is highly likely*

Question 250

This arrhythmia is manifested by sudden onset and sudden termination, rates of 140-250 bpm with regular rhythm, and narrow compleses without definite P waves

Answer 250

Paroxysmal supraventricular tachycardias (PSVTs) * The mechanism of PSVT is often due to formation of a supraventricular re-entry circuit, most commonly within the AV node (AVNRT). AVNRT results from a reentrant circuit formed by two separate conducting pathways (one fast and the other slow) within the AV node* * Another common cause of PSVT is atrioventricular reentry tachycardia (AVRT). Here, it is caused by a bypass tract separate from the normal conduction system that connects the atria and ventricular tissue. The most common example of AVRT is Wolff-Parkinson-White (WPW) pre-excitation syndrome, which predisposes to PSVTs since the accessory pathway (eg, bundle of Kent) provides a potential limb for reentrant loop formation.*

Question 251

What symptom in addition to diarrhea differentiates viral gastroenteritis from a bacterial gastroenteritis?

Answer 251

Viral gastroenteritis usually results in vomiting in addition to diarrhea

Question 252

What is the first step in the management of asymptomatic diverticulosis?

Answer 252

Increase dietary fiber intake ## Footnote *Bowel rest and antibiotics are administered to patients with uncomplicated diverticulitis. Diverticulosis is differentiated from diverticulitis by the absence of fever, leukocytosis, or other signs of peritoneal inflammation.*

Question 253

Epigastric pain that worsens with eating is typical of what

Answer 253

Gastric ulcer

Question 254

What is the most likely diagnosis in a patient with a subacute to chronic presentation of abdominal pain, tenesmus, and bloody diarrhea ## Footnote *Tenesmus = Constant feeling of needing to defecate despite an empty rectum*

Answer 254

Inflammatory Bowel Disease (IBD) ## Footnote *In patients with IBD and worsening symptoms accompanied by signs of sepsis, toxic megacolon should be considered and an abdominal radiograph ordered to confirm the diagnosis.*

Question 255

Low pulmonary capillary wedge pressure, low systemic vascular resistance, increased cardiac output, and high mixed venous oxygen saturation are characteristic of what?

Answer 255

Septic shock

Question 256

In patients with suspected stroke, what is the initial diagnostic test of choice?

Answer 256

Non-contrast head CT, which is critical for guiding further management

Question 257

What does hyponatremia in a heart failure patient indicate?

Answer 257

Hyponatremia indicates severe CHF *Water retention and the associated reduction in the plasma sodium concentration parallel the severity of the heart disease; they reflect the degree of neurohumoral activation in patients with heart failure. Low serum sodium level is associated with high levels of renin, aldosterones, vasopressin, and norepinephrine. As a result, a patient's survival is significantly reduced if the serum sodium level is below 137mg/dL.*

Question 258

What is one of the common causes of lactic acidosis in patients with severe atherosclerotic disease or atrial fibrillation?

Answer 258

Unrecognized bowel ischemia *This would be particularly likely in a patient with acute abdominal pain and nausea accompanied by hypoactive bowel sounds and abdominal tenderness on physical exam.*

Question 259

Holosystolic murmur that increases on inspiration is indicative of what?

Answer 259

Tricuspid regurgitation

Question 260

What are the drugs of choice for diabetic neuropathy?

Answer 260

Tricyclic antidepressants (TCA) *TCAs can worsen urinary symptoms and orthostatic hypotension. Gabapentin is an alternative for these patients. NSAIDs can also be used but are contraindicated in patients with renal dysfunction.*

Question 261

An acute, severe presentation of endocarditis in a patient with previously normal heart valves is suggestive of which bacteria?

Answer 261

Staph Aureus

Question 262

What is the first step in treatment of 3rd degree heart block?

Answer 262

Expeditious pacemaker placement *This is because the rhythm can degenerate into ventricular tachycardia or ventricular fibrillation*

Question 263

Any patient who returns from a developing country and has symptoms suggestive of malabsorption should be considered for empirical treatment with what?

Answer 263

Metronidazole ## Footnote *This is for suspected giardiasis. If the patient had instead travelled to a different location (like the Rocky Mountains) the answer is the same: Giardiasis*

Question 264

What drug class is recommended as first-line therapy for controlling anginal symptoms and improving exercise tolerance in stable angina pectoris?

Answer 264

Beta-blockers *They reduce myocardial oxygen demand by decreasing heart rate and myocardial contractility. Beta-blockers should be avoided in patients with hypotension or bradycardia. Calcium-channel blockers or long-acting nitrates are used if beta blockers are contraindicated.*

Question 265

What is the management of actively bleeding esophageal varices?

Answer 265

Hemodynamic support Octreotide Endoscopic therapy Prophylactic antibiotics

Question 266

PAS-positive material in the lamina propria of the small intestine is a classical biopsy finding of what condition?

Answer 266

Whipple's disease ## Footnote *This is a rare, multi-systemic illness that is caused by the bacillus Tropheryma whippelii. It is most commonly seen in white men in the fourth-to-sixth decades of life, and often presents with weight loss.*

Question 267

What typically presents with dysphagia for solids and liquids, heartburn, regurgitation of food, and weightloss?

Answer 267

Achalasia ## Footnote *Achalasia is an idiopathic esophageal motility disorder that causes loss of peristalsis in the distal esophagus and prevents lower esophageal sphincter (LES) relaxation during swallowing. Barium swallow usually shows a dilated esophagus with distal narrowing, and manometry shows lower esophageal sphincter abnormalities. Esophageal malignancy at the esophageal-gastric junction can mimic achalasia and should be excluded with endoscopy before starting treatment for achalasia.*

Question 268

What is the treatment for uric acid kidney stones?

Answer 268

1. Hydration 2. Alkalinization of urine 3. Low-purine diet ## Footnote *Since uric acid stones are highly soluble in alkaline urine, alkalinization of the urine to pH \>6.5 with oral potassium bicarbonate or potassium citrate is indicated.*

Question 269

By what mechanism does exudative ascites occur?

Answer 269

Increased capillary permeability

Question 270

What test should be ordered in a patient with inflammatory bowel disease (IBD) and worsening symptoms accompanied by signs of sepsis?

Answer 270

Abdominal radiograph ## Footnote *The presentation is suggestive of toxic megacolon. An abdominal X-ray should be ordered to confirm this diagnosis.*

Question 271

What effect does a sustained hand grip have on hemodynamics?

Answer 271

Sustained hand grip leads to an increase in systemic vascular resistance and increased afterload

Question 272

Widened pulse pressure, strong peripheral arterial pulsation (e.g. brisk carotid upstroke), systolic flow murmur, tachycardia, usually flushed extremities, and LVH on ECG with point of maximal impulse displaced to the left are all signs of what?

Answer 272

Arteriovenous fistula (AVF) *Shunting of a large amount of blood through the fistula decreases systemic vascular resistance, increases cardiac preload, and increases cardiac output.*

Question 273

What is the most important feature of Selenium deficiency?

Answer 273

Cardiomyopathy ## Footnote *Selenium deficiency, like zinc deficiency, may result from chronic total parenteral nutrition.*

Question 274

1. What do calcium renal stones look like on CT scan of the abdomen? 2. What do uric acid renal stones look like on CT scan of the abdomen?

Answer 274

1. Radioopaque 2. Radiolucent

Question 275

What is the classic triad of disseminated gonococcal infection?

Answer 275

1. Polyarthralgia 2. tenosynovitis (pain along tendon sheaths) 3. Painless vesicopustular skin lesions

Question 276

What are 4 potential complications of acute pancreatitis?

Answer 276

1. Pleural effusion 2. Acute respiratory distress syndrome 3. Ileus 4. Renal Failure ## Footnote *These complications are often due to activated pancreatic enzyme (I.E. Phospholipase, trypsin) and cytokines (I.E. tumor necrosis factor) that are released from the inflamed pancreas into the circulation and cause inflammation in other parts of the body.*

Question 277

Crypt abscesses are characteristic of what condition?

Answer 277

Ulcerative colitis

Question 278

What is the treatment for hemodynamically unstable patients with atrial fibrillation?

Answer 278

Immediate DC cardioversion *DC cardioversion has a higher success rate than Amiodarone and Quinidine and is less likely to induce an arrhythmia. The success of cardioversion in a patient with recent-onset a-fib is approximately 90%.*

Question 279

What is the most common cause of iron deficiency anemia in an elderly patient?

Answer 279

Gastrointestinal blood loss ## Footnote *The next step in evaluation would be a colonoscopy. A single negative occult blood test does not exclude the possibility of gastrointestinal bleeding.*

Question 280

What diagnosis should be suspected in patients with recurrent episodes of hematuria, sensorineural deafness, and a family history of renal failure?

Answer 280

Alport's syndrome ## Footnote *This is a familial disorder which usually presents in childhood as recurrent gross hematuria and proteinuria. Sensorineural deafness usually occurs. Electron microscopy findings include alternating areas of thinned and thickened capillary loops with splitting of the glomerular basement membrane (GBM).*

Question 281

In patients with preexisting heart disease, what hemoglobin level should be maintained?

Answer 281

_\>_10g/L (or hematocrit _\>_30%)

Question 282

What is the treatment for toxic megacolon?

Answer 282

1. IV fluids, antibiotics, and bowel rest 2. IV corticosteroids are the drugs of choice for IBD-induced toxic megacolon 3. Emergency surgery (subtotal colectomy with end-ileostomy is the procedure of choice) may be required if the colitis does not resolve

Question 283

Acute vertigo is often due to what?

Answer 283

Dysfunction of the labyrinth, as in benign paroxysmal positional vertigo (BPPV) 30% of BPPV cases occur after head trauma but typically no precipitating causes are found.

Question 284

What is the first-line treatment for carcinoid tumors?

Answer 284

Complete surgical removal ## Footnote *It can result in a permanent cure if it is possible to remove the tumor entirely. The mainstay of treatment for advanced carcinoid tumors that cannot be removed surgically is octreotide injection.*

Question 285

What is the 1st step in management of blunt abdominal trauma in a hemodynamically unstable patient?

Answer 285

Focused Assessment with Sonography for Trauma (FAST) examination ## Footnote *This assessment is done to rapidly detect the presence of intra-abdominal organ injury or hemoperitoneum. A positive test would be followed by an exploratory laparotomy. An inconclusive test would be followed by a diagnostic peritoneal lavage. A negative test in the absence of signs of extra-abdominal hemorrhage would be followed by a CT of the abdomen after the patient was hemodynamically stable.*

Question 286

What do ethanol and sedative withdrawals cause that opioid withdrawal does not?

Answer 286

Seizures

Question 287

What are the two diagnostic studies of choice for aortic dissection?

Answer 287

1. Transesophageal echocardiography 2. CT chest with contrast

Question 288

What two immunosuppressants are implicated in causing optic neuritis?

Answer 288

Ethambutol and Hydroxychloroquine

Question 289

The absence of peristaltic waves in the lower two-thirds of the esophagus and significant decrease in lower esophageal sphincter (LES) tone are characteristic of what?

Answer 289

Esophageal dysmotility ## Footnote *This is associated with scleroderma.*

Question 290

Patients with Hashimoto's thyroiditis are at increased risk for developing what type of cancer?

Answer 290

Thyroid lymphoma

Question 291

What is the fluid of choice to be administered to a hypotensive, dehydrated patient with Diabetes Insipidus?

Answer 291

Normal saline *Hypotonic fluids can be started when the intravascular volume improves.*

Question 292

ST elevation in leads II, III, and aVF indicates what?

Answer 292

Inferior wall MI

Question 293

1. Bloody diarrhea **+** abdominal tenderness **-** fever is most suggestive of what? 2. Bloody diarrhea **+/-** abdominal tenderness **+** fever is most suggestive of what?

Answer 293

1. Infection with Enterohemorrhagic E. Coli (EHEC) 2. Shigella, Slamonella, and Campylobacter

Question 294

What are the names of the two antithyroid drugs which are available for use in the USA?

Answer 294

1. Propylthiouracil (PTU) 2. Methimazole (MMI) *Aproximately 30-40% of patients treated with antithyroid drugs for 1 year go into permanent remission*

Question 295

How is the diagnosis of achalasia made?

Answer 295

1. Barium swallow 2. Manometry 3. Endoscopy ## Footnote *Barium swallow is performed when achalasia is suspected and classically shows "bird-beak" narrowing at the gastroesophageal junction. The diagnosis is then confirmed with manometry which shows elevated resting lower esophageal sphincter (LES) pressure, incomplete LES relaxation after swallowing, and/or absence of peristalsis in the esophageal body. Before treatment is begun, endoscopy should be performed to rule out gastroesophageal malignancy.*

Question 296

What is the most sensitive test for identifying vertebral osteomyelitis?

Answer 296

MRI of the spine *Bone scan has similar sensitivity to MRI in the diagnosis of vertebral osteomyelitis but it has inferior specificity*

Question 297

What is the medical treatment for benign prostatic hyperplasia (BPH)?

Answer 297

1. Alpha 1-blockers (doxazosin or tamsulosin are usually preferred) 2. 5-alpha reductase inhibitors (Finasteride) ## Footnote *Alpha 1-blockers alone or in combination with 5-alpha reductase inhibitors are first-line for symptomatic relief. Surgery may be required for patients with severe symptoms (I.E. bladder outlet obstruction or recurrent urinary tract infections) or failing medical therapy.*

Question 298

The strongest predictors of abdominal aortic aneurysm expansion and rupture are what?

Answer 298

1. Larger aneurysm diameter 2. Current cigarette smoking

Question 299

In general, what is the most common nephropathy associated with carcinoma?

Answer 299

Membranous glomerulonephritis (often seen in patients with carcinomas of the lung, stomach, breast, and colon)

Question 300

Aortic stenosis in a young individual is usually the result of what?

Answer 300

A congenitally bicuspid aortic valve.

Question 301

Why does total parental nutrition (TPN) cause cholecystitis?

Answer 301

TPN causes gallbladder stasis and predisposes to gallstone formation and bile sludging

Question 302

What usually presents with sudden onset of tearing chest and back pain, usually in the setting of uncontrolled hypertension?

Answer 302

Acute aortic dissection

Question 303

Immediate surgical intervention is indicated for patients with intestinal obstruction in what 3 circumstances?

Answer 303

1. Development of hemodynamic instability 2. Failure to improve after initial conservative measures 3. Development of signs of strangulation ## Footnote *Most small bowel obstruction patients can be managed initially with conservative measures, including complete bowel rest, decompression with nasogastric tube placement, pain control, fluid resuscitation, and correction of metabolic derangements. Patients who do not improve with conservative measures and/or develop symptoms or signs of strangulation should be referred for urgent surgical intervention.*

Question 304

In any patient, what two lab values provide the best picture of acid-base status?

Answer 304

pH and PaCO₂ ## Footnote *The HCO₃^- can be calculated from these values using the Henderson-Hasselbach equation. The PO2 gives information about a patient's oxygenation status. The urinary pH can give information about renal handling of acids and bases, but it can not be used to determine a patient's serum acid-base status with the same clarity that pH, HCO₃^- and PaCO₂ can.*

Question 305

Paroxysmal supraventricular tachycardia (PSVT) most commonly results from accessory conduction pathways through the AV node. What can be effective in resolving PSVT?

Answer 305

Vagal maneuvers and medications that decrease conduction through the AV node

Question 306

What is the treatment for adults with scabies?

Answer 306

5% permethrin cream which is applied from the neck down and left overnight. Repeat in 14 days if live mites are still present. *Low-potency steroids can be added to treat the dermatitis*

Question 307

What is elevated in the serum of a person at bedrest?

Answer 307

Calcium ## Footnote *It has an unclear underlying mechanism but is likely due to increased osteoclastic bone resorption. The risk is increased in patients with pre-existing high bone turnover (I.E. younger individuals or older individuals with Paget's disease). Hypercalcemia occurs within days of immobilization of these individuals.*

Question 308

What are some general symptoms of hypercalcemia

Answer 308

1. Constipation 2. Fatigue 3. Excessive urination

Question 309

What is the drug of choice in treating classic benign essential tremor?

Answer 309

Propranolol

Question 310

What is the management of Pulseless electrical activity (PEA)?

Answer 310

Uninterrupted cardiopulmonary resuscitation along with vasopressor therapy to maintain adequate cerebral and coronary perfusion *Potentially reversible causes of PEA should also be investigated. Defibrillation or synchronized cardioversion has no role in the management of these patients*

Question 311

What is the most appropriate initial treatment for decompensated heart failure?

Answer 311

IV diuretics *They provide symptomatic benefits to patients with decompensated heart failure*

Question 312

What is the inheritance pattern of hypertrophic cardiomyopathy?

Answer 312

Autosomal dominant

Question 313

Which two drugs are notorious for causing priapism?

Answer 313

Prazosin and Trazodone

Question 314

What is the management of choice in preventing stroke in patients with lone atrial fibrillation? ## Footnote *Lone a-fib is defined as the presence of paroxysmal (recurrent \>2 episodes that terminate spontaneously in 7 days), or permanent (persistent with no further plans for rhythm control) atrial fibrillation with no evidence of cardiopulmonary or structural disease.*

Answer 314

No additional therapy is indicated ## Footnote *These patients are at low risk of systemic embolization (CHADS2 score of 0).*

Question 315

What is the initial investigation of choice for suspected acalculous cholecystitis

Answer 315

Ultrasonogram, which shows signs of acute cholecystitis and no gallstones; however, CT scan and HIDA scans are more sensitive and specific for the diagnosis.

Question 316

Opioid withdrawal presents with what symptoms?

Answer 316

1. Nausea 2. Vomiting 3. Abdominal pain 4. Diarrhea 5. Restlessness 6. Arthralgias 7. Myalgias

Question 317

What is the first step in evaluation of a patient under the age of 50 years with no cancer risk factors, who has minimal bright red blood per rectum?

Answer 317

Anoscopy/proctoscopy ## Footnote *Office based anoscopy/proctoscopy are simple maneuvers that have a high yield and do not require bowel preparation. Anoscopy has higher sensitivity for diagnosing hemorrhoids than flexible endoscopy.*

Question 318

Nephrotoxicity, hyperkalemia, hypertension, gum hypertrophy, hirsutism, and tremor are all side effects of what drug?

Answer 318

Cyclosporine ## Footnote *Cyclosporine is a commonly used immunosuppressant. It acts by inhibiting the transcription of interleukin-2 and several other cytokines, mainly the T-helper lymphocytes. Tacrolimus has similar toxicities, except for hirsutism and gum hypertrophy.*

Question 319

By what mechanism does transudative ascites occur?

Answer 319

Increased hydrostatic pressure

Question 320

What is essential in distinguishing between dementia and normal changes of aging?

Answer 320

Impairment of daily functioning

Question 321

Pulsus paradoxus refers to a fall in the systemic arterial pressure by more than 10 mmHg during inspiration, and is often associated with what?

Answer 321

Cardiac Tamponade

Question 322

What causes arterial pressure to fall \>10mm Hg during inspiration?

Answer 322

This is called Pulsus paradoxus and is most commonly seen in cardiac tamponade but can also be seen in asthma and COPD ## Footnote * Cardiac tamponade: During inspiration, increased systemic venous return to the right heart causes the interventricular septum to shift into the left ventricular cavity, reducing left ventricular end diastolic volume. This leads to decreased stroke volume and reduced systolic BP* * Asthma/COPD: Normally, there is a small variation in intrathoracic pressure with respiration, which drops 2-5mmHg below atmospheric pressure during inspiration. In patients with COPD/asthma, the drop in intrathoracic pressure upon inspiration is exaggerated up to 40mmHg. This negative pressure causes pooling of blood in the pulmonary vasculature, decreasing left ventricular preload.*

Question 323

What condition is characterized by chest pain; dysphagia; and periodic, high-amplitude, non-peristaltic waves on manometry?

Answer 323

Diffuse esophageal spasm

Question 324

What is the treatment of a hydatid cyst?

Answer 324

Surgical resection under the cover of albendazole.

Question 325

The following signs/symptoms are characteristic of what diagnosis? 1. Flushing 2. Diarrhea 3. Wheezing

Answer 325

Carcinoid syndrome ## Footnote *Carcinoid syndrome is a constellation of symptoms that are exhibited by patient with carcinoid tumors. Such carcinoid tumors may occur in the small intestine, colon, bronchial tubes, or appendix. These tumors secrete excessive amounts of the hormone serotonin, as well as other chemicals that cause the blood vessels to dilate. Patients typically manifest with the classic triad of flushing, diarrhea, and wheezing. Episodic flushing is the clinical hallmark of carcinoid syndrome, occuring in approximately 85% of patients.*

Question 326

What is the most common type of neuropathy found in diabetics?

Answer 326

Symmetrical distal polyneuropathy

Question 327

What effect does squatting have on hemodynamics?

Answer 327

Squatting decreases the vertical height of the blood column, and therefore will increase venous return to the heart *Recumbency and leg raising have the same effect*

Question 328

What effect does the valsalva maneuver have on hemodynamics?

Answer 328

It decreases venous return and thus decreases preload *Standing from a crouched position has the same effect*

Question 329

Positive anti-thyroperoxidase (TPO) antibodies with an enlarged rubbery goiter is virtually diagnostice of what?

Answer 329

Hashimoto's thyroiditis *Patients with this condition can be hypothyroid, euthyroid, or even hyperthyroid early in the disease process due to thyroid-stimulating antibodies or the release of thyroid hormones from inflammation.*

Question 330

Patients \> 55 years with new-onset symptoms of dyspepsia and those of any age who have alarm symptoms (weight loss, dysphagia, or persistent vomiting) should be evaluated with what?

Answer 330

Upper endoscopy

Question 331

What is the most appropriate empiric antibiotic regimen for a patient \>55 years old with suspected acute bacterial meningitis?

Answer 331

Vancomycin, Ceftriaxone, and Ampicillin _**Vancomycin** + **Ceftriaxone** is ideal for community acquired bacterial meningitis in adults and children since it covers the three most frequent agents: Strep pneumo, H. Flu, and N. Meningitidis. **Ampicillin** is included in the empiric regimen to cover Listeria, which is important in patients over 55 y/o or those who are immunocompromised_

Question 332

What is the treatment of choice for a patient with acute limb ischemia?

Answer 332

Surgical embolectomy or intra-arterial fibrinolysis/mechanical embolectomy via interventional radiology *While intravenous infusion of a fibrinolytic agent is an option for STEMI patients, patients with acute limb ischemia typically are treated with direct intra-arterial, not intravenous, administration of a fibrinolytic agent on the clot using an angiographic catheter*

Question 333

What cause of syncope is preceded by nausea, diaphoresis, tachycardia, and pallor?

Answer 333

Neurocardiogenic (vasovagal) syncope.

Question 334

Marfanoid habitus is seen in what type of multiple endocrine neoplasia (MEN) syndrome?

Answer 334

MEN type 2B ## Footnote *MEN 2B patients can develop medullary thyroid cancer, pheochromocytoma, marfanoid habitus, and intestinal or mucosal neuromas.*

Question 335

What is the most likely diagnosis in a patient with massive increases in AST and ALT a day after presenting with shock?

Answer 335

Ischemic hepatic injury (shock liver) ## Footnote *The hallmark of ischemic hepatopathy is a rapid and massive increase in the transaminases with modest accompanying elevations in total bilirubin and alkaline phosphatase. In patients who survive the underlying cause of their hypotension, liver enzymes typically return to normal within one to two weeks.*

Question 336

What is the most appropriate initial intervention for acute aortic dissection?

Answer 336

Beta-blocker *Type-A dissections involve the ascending aorta and are treated with medical therapy and surgery. Type-B dissections involve only the descending aorta and are usually treated with medical therapy alone.*

Question 337

What often occurs 5 days to 3 months after initial MI and presents with persistent ST-segment elevation and deep Q waves in the same leads on ECG, and mitral annular dilatation with mitral regurgitation?

Answer 337

Left ventricular aneurysm *Papillary muscle rupture causes mitral regurg following an MI but this occurs 2-7 days post MI and is not associated with persistent ST-segment elevation on ECG*.

Question 338

When pleural effusion is suspected or diagnosed, the first step is to determine the cause of the pleural effusion, and management starts with determining whether the fluid is transudate or exudate. What is the preliminary investigation of choice?

Answer 338

Thoracentesis is the preliminary investigation of choice in the management of pleural effusion, except in patients with classic signs and symptoms of congestive heart failure, where a trial of diuretic is warranted *Bronchoscopy is a close alternative to thoracentesis, however, it requires sedation and is considered relatively invasive. It would be the next step if the pleural fluid cytology is non-diagnostic and the patient had a lung mass. If the pleural fluid cytology was positive for lung cancer, bronchoscopy is not necessary.*

Question 339

What happens to Aldosterone levels in adrenal insufficiency secondary to long-term supraphysiologic doses of prednisone suppressing the hypothalamic pituitary adrenal (HPA) axis?

Answer 339

Aldosterone secretion is relatively preserved in such patients because ACTH has a very modest effect on its secretion. ## Footnote *Glucocoritcoids suppress corticotropin-releasing hormone (CRH) secretion from the hypothalamus and also block the action of CRH on the anterior pituitary to release ACTH. ACTH acts on the adrenal cortex and is responsible for the secretion of cortisol and androgen from the zona fasciculata and zona reticularis, respectively. ACTH has a very mosdest stimulatory effect on aldosterone secretion from the zona glomerulosa of the adrenal cortex. Due to the differential effect of ACTH on the adrenal cortex, aldosterone levels are relatively normal with deficiency of ACTH in central adrenal insufficiency.*

Question 340

What finding differentiates Dubin-Johnson syndrome from Rotor syndrome?

Answer 340

Dark granular pigment of hepatocytes in Dubin-Johnson syndrome ## Footnote *Dubin-Johnson and Rotor syndrome are two familial disorders of hepatic bile secretion that results in conjugated hyperbilirubinemia. A dark granular pigment is present in the hepatocytes of patients with Dubin-Johnson syndrome, but is not seen in association with Rotor syndrome.*

Question 341

What can result in restrictive cardiomyopathy with thickened ventricular walls and preserved ventricular dimensions, as well as involvement of the liver and kidneys?

Answer 341

Amyloidosis *In amyloidosis, extracellular deposition of excess proteins results in organ dysfuction. Deposition of amyloid fibrils in the kidney can result in proteinuria. Binding of amyloid fibrils to the liver can inhibit the synthesis of coagulation factors, resulting in increased bruisability. In the heart, amyloid deposition leads to restrictive cardiomyopathy with thickened ventricular walls and diastolic dysfunction. Systolic function is relatively well preserved, and ventricular dimensions remain unchanged.*

Question 342

Aside from giving atropine to a patient with organophosphate poisoning, what should be an initial step in management?

Answer 342

Removal of patient's clothes (which may be contaminated with pesticides) and washing of the skin to prevent further transcutaneous absorption.

Question 343

What are some symptoms of digoxin toxicity?

Answer 343

1. Nausea 2. Vomiting 3. Decreased appetite 4. Confusion 5. Weakness 6. Visual symptoms such as scomata, blurry vision with changes in color, or even blindness

Question 344

What is the most common cause of acquired angioedema?

Answer 344

ACE inhibitors *Angioedema caused by ACE inhibitors can occur anytime during treatment, not just within the first few weeks of starting the medication*

Question 345

What condition is more common in elderly males and presents with dysphagia, regurgitation, foul-smelling breath, aspiration, and possibly a palpable mass?

Answer 345

Zenker's diverticulum ## Footnote *A contrast esophagram is the test of choice for confirming the diagnosis. Treatment is generally surgical.*

Question 346

What is the mainstay of treatment for advanced carcinoid tumors that cannot be removed surgically?

Answer 346

Octreotide injection ## Footnote *In many cases, this anti-hormone drug inhibits and sometimes reverses the growth of the tumors.*

Question 347

What presents as severe abdominal pain that is out of proportion to the clinical exam?

Answer 347

Mesenteric ischemia

Question 348

What is Flecainide typically used to treat?

Answer 348

Ventricular arrhythmias and supraventricular tachycardias such as atrial fibrillation.

Question 349

What diagnosis should be suspected in any patient with malabsorption and iron deficiency anemia?

Answer 349

Celiac disease ## Footnote *IgA anti-endomysial and anti-tissue transglutaminase antibodies are highly predictive of celiac disease but may be absent if there is concurrent selective IgA deficiency (which is common in celiac disease).*

Question 350

What is the most common adverse effect of inhaled corticosteroid therapy?

Answer 350

Oropharyngeal thrush

Question 351

The following findings are consistent with what diagnosis? 1. Palpable purpura 2. Glomerulonephritis 3. Non-specific symptoms 4. Arthralgias 5. Hepatosplenomegaly 6. Peripheral neuropathy 7. Hypocomplementemia

Answer 351

Mixed essential cryoglobulinemia ## Footnote *Most patients also have hepatitis C*

Question 352

What is the most common side effect and most serious side effect of antithyroid drug therapy?

Answer 352

1. Most common: Allergic reaction (2% of patients) 2. Most serious: Agranulocytosis (0.3% of patients)

Question 353

What is the most commonly affected system of the body that is involved as a side affect of digoxin use?

Answer 353

Gastrointestinal system ## Footnote *This includes anorexia, nausea, and vomiting.*

Question 354

What is the mechanism of polycythemia in obstructive sleep apnea (OSA)?

Answer 354

Hypoxemia-induced increases in erythropoietin production ## Footnote *Treatment of OSA causes the polycythemia to improve.*

Question 355

What is the treatment for Goodpasture's syndrome?

Answer 355

Plasmapheresis ## Footnote *Goodpasture's syndrome is caused by circulating anti-glomerular basement membrane antibodies. Early removal of these antibodies by emergency plasmapheresis is imperative in order to minimize the extent of kidney damage. Emergency plasmapheresis improves the prognosis of patients.*

Question 356

What pharmacological agent is used in the treatment of active esophageal variceal bleeding but has no role in primary prophylaxis of variceal hemorrhage?

Answer 356

Octreotide ## Footnote *This is a long-acting analog of somatostatin that causes splanchinc vasoconstriction and reduced portal blood flow by inhibiting the release of glucagon.*

Question 357

What annual surveillance test is recommended for patients with Ulcerative colitis (UC)?

Answer 357

Colonoscopy ## Footnote *Routine surveillance with yearly colonoscopies is recommended for patients with UC beginning 8-10 years after diagnosis for prevention and/or early detection of colon cancer.*

Question 358

What are the two most common pathologies seen in analgesic nephropathy?

Answer 358

1. Papillary necrosis 2. Chronic tubulointerstitial nephritis *Analgesic nephropathy is the most common form of drug-induced chronic renal failure. Polyuria and sterile pyuria (WBCs may also be seen) are early manifestations. Microscopic hematuria and renal colic may occur following sloughing of renal papilla. Hypertension, mild proteinuria, and impaired urinary concentration commonly occur as the disease advances. Patients with chronic analgesic abuse are also more likely to develop premature aging, atherosclerotic vascular disease, and urinary tract cancer.*

Question 359

Severe hypertension with retinal hemorrhages, exudates, or papilledema is called what?

Answer 359

Malignant hypertension

Question 360

What condition is characterized as a myeloproliferative disease that causes a clonal proliferation of myeloid cells?

Answer 360

Polycythemia vera ## Footnote *In polycythemia vera, the concentrations of all blood cell lines are increased.*

Question 361

What is the treatment of choice for premature atrial contractions?

Answer 361

Nothing/Observation *PACs are benign and neither require any treatment or follow-up*

Question 362

Asymptomatic funguria is common in patients with longstanding indwelling urinary catheters. What is the appropriate management of a case of uncomplicated asymptomatic funguria?

Answer 362

Replace catheter ## Footnote *Empiric antifungal agents are generally unnecessary.*

Question 363

What are the most sensitive and specific tests for the diagnosis of acute pancreatitis?

Answer 363

Serum amylase and lipase levels

Question 364

The presence of a systolic-diastolic abdominal bruit in a patient with hypertension and atherosclerosis is strongly suggestive of what?

Answer 364

Renal artery stenosis

Question 365

What pharmalogical agents are used to treat Variant (Prinzmetal's agina)?

Answer 365

Calcium channel blockers and/or nitrates *They prevent coronary vasospasm*

Question 366

Procainamide is used to treat what?

Answer 366

Atrial and ventricular arrhythmias *Potential side effects include nausea, drug-induced lupus, agranulocytosis, and _QT prolongation._*

Question 367

What diagnosis is suggested by dysuria, urinary frequency, suprapubic discomfort and urinary findings of bacteriuria and pyuria?

Answer 367

Bacterial cystitis ## Footnote *Mucopurulent cervical discharge is not found. Urine culture shows colonies in excess of 1000/mL.*

Question 368

Accelerated atherosclerosis is seen in what renal condition?

Answer 368

Nephrotic syndrome ## Footnote *Nephrotic syndrome can result in alterations in lipid metabolism. This dyslipidemia puts affected patients at increased risk for accelerated athersclerosis. This atherosclerotic tendency, along with intrinsic hypercoagulability, places patients with nephrotic syndrome at risk for complications such as stroke and myocardial infarction.*

Question 369

Painless jaundice in a patient with conjugated hyperbilirubinemia and markedly elevated alkaline phosphatase should raise concern for what diagnosis?

Answer 369

Pancreatic or biliary cancer ## Footnote *Likely etiologies include pancreatic adenocarcinoma or cholangiocarcinoma. The next step in evaluation would be abdominal imaging (ultrasound or Computed tomography), with consideration for endoscopic retrograde cholangiopancreatography (ERCP) if initial imaging is nondiagnostic.*

Question 370

What is the most appropriate management of progressive pain in a patient with prostate cancer and bony metastases after androgen ablation (orchiectomy)?

Answer 370

Radiation therapy ## Footnote *Etidronate disodium and other bisphosphonates may be useful in patients with bony metastasis as it reduces bone resorption. It is useful in controlling chronic pain from bony metastasis, but its onset of action in alleviating acute bone pain is not as rapid as radiation therapy.*

Question 371

What is the most critical factor determining the overall patient survival in sudden cardiac arrest?

Answer 371

Elapsed time to effective resuscitation *This includes effective CPR, prompt rhythm analysis, and early defibrillation for patients found to be in ventricular fibrillation. Ventricular fibrillation almost never terminates spontaneously and early rhythm analysis and defibrillation are the only effective means to reestablish perfusing cardiac rhythm and improve patient survival*

Question 372

Esophageal pH monitoring is typically used to confirm what diagnosis?

Answer 372

Gastroesophageal reflux (GERD)

Question 373

In ventricular fibrillation and pulseless ventricular tachycardia, what is of primary importance?

Answer 373

Defibrillation *Time to defibrillation is strongly correlated with survival*

Question 374

What is the major cause of mordity/mortality in patients with subarachnoid hemorrhage?

Answer 374

Vasospasm with symptomatic ischemia/infarction

Question 375

A barium swallow revealing a "corkscrew" esophagus is suggestive of what diagnosis?

Answer 375

Diffuse esophageal spasm The esophagogram is frequently normal, although the classic corkscrew esophagus is seen occasionally.

Question 376

What is the primary treatment for hemochromatosis?

Answer 376

Phlebotomy

Question 377

Pulsus parvus (decreased pulse amplitude) and pulsus tardus (delayed pulse upstroke) are associated with what?

Answer 377

Aortic stenosis

Question 378

What is the treatment of hepatic hydrothorax?

Answer 378

1. Salt restriction and diuretics 2. Transjugular intrahepatic portosystemic shunt (TIPS) for refractory disease ## Footnote *Hepatic hydrothorax is a cause of transudative pleural effusions in patients with cirrhosis who have no underlying cardiac or pulmonary disease to account for development of such an effusion. Hepatic hydrothorax usually results in a right-sided pleural effusion. Initial treatment is usually with salt restriction and diuretics. TIPS placement is considered in patients with refractory hepatic hydrothorax.*

Question 379

Hemodynamically unstable ventricular tachycardia should be treated with what?

Answer 379

Emergent DC cardioversion

Question 380

This electrolyte abnormality causes weakness, fatigue, and muscle cramps. When severe, it can lead to paralysis and arrhythmia. The ECG may show U waves, flat and broad T waves, and premature ventricular beats

Answer 380

Hypokalemia

Question 381

What diagnosis is confirmed by renal deposits that show apple-green birefringence under polarized light after staining with congo red?

Answer 381

Amyloidosis ## Footnote *A history of rheumatoid arthritis, enlarged kidneys, and hepatomegaly should raise suspicion for amyloidosis. The typical findings on renal biopsy in such a patient are amyloid deposits that show apple-green birefringence under polarized light after staining with Congo red. Extracellular amyloid fibrils demonstrated on electron microscopy are also typical.*

Question 382

Hematuria following an upper respiratory infection is a common presentation of which nephrotic syndrome?

Answer 382

IgA nephropathy

Question 383

1. Cyclophosphamide is an alkylating agent frequently used as an immunosuppressant in what conditions? 2. What are some serious side effects?

Answer 383

1. Systemic Lupus Erythematosus, vasculitis, and certain cancers 2. Acute hemorrhagic cystitis, bladder carcinoma, sterility, and myelosuppression ## Footnote *(Hemorrhagic cystitis and bladder cancer are caused by a bladder-toxic metabolite of cyclophosphamide called acrolein)*

Question 384

What do Kayexalate and sodium polystyrene do?

Answer 384

They are cation-exchange resins that act in the GI tract by promoting the exchange of Na for K, and thereby increasing the ecretion of K+

Question 385

Enthesitis (pain and inflammation at sites where tendons and ligaments attach to bone) is most commonly seen in cases of recurrent tendon/ligament stress or in what?

Answer 385

HLA-B27-associated arthropathies and is particularly prominent in ankylosing spondylitis where it often manifests with heel pain due to tenderness at the insertion of the achilles tendon.

Question 386

What is the appropriate treatment for acute pancreatitis?

Answer 386

1. Analgesics 2. Intravenous fluids 3. Nothing by mouth ## Footnote *Acute pancreatitis is one of numerous conditions that cause an acute abdomen. It is managed conservatively, as most attacks are self-limiting and subside in 4-7 days with conservative treatment. This treatment regimen should include analgesics for pain (with meperidine or fentanyl favored over morphine), intravenous fluids to maintain intravascular volume, and no oral alimentation as a means of avoiding further pancreatic inflammation.*

Question 387

Cardiogenic pulmonary edema results from left heart failure and is characterized by crackles on pulmonary exam. What is the most rapidly acting medication to relieve the symptoms of pulmonary edema?

Answer 387

Nitroglycerin ## Footnote *It relieves the dyspnea and tachycardia associated with cardiogenic pulmonary edema by rapidly reducing preload. Several studies have suggested that it works quicker than morphine or loop diuretics. Nitroglycerin is not part of the long-term management for patients with heart failure but can be beneficial in acutely alleviating symptoms.*

Question 388

Lupus anticoagulant, or anti-phospholipid antibody, is a prothrombotic immunoglobulin that causes what laboratory abnormality?

Answer 388

Falsely prolonged PTT

Question 389

Stored red blood cells gradually leak what substance?

Answer 389

Potassium ## Footnote *Stored red blood cells gradually lose intracellular potassium to the surrounding solution. This mechanism has the potential to cause hyperkalemia.*

Question 390

What causes hypocalcemia in a patient following a blood transfusion?

Answer 390

Chelation of calcium by citrate ## Footnote *Citrate is a substance that is added to stored blood. It chelates calcium and magnesium and may reduce their plasma levels, causing paresthesias*

Question 391

What are some symptoms and signs of mitral stenosis?

Answer 391

_Symptoms_ 1. Progressive dyspnea on exertion 2. Orthopnea 3. Hemoptysis _Signs_ 1. Left atrial enlargement 2. Elevation of left main bronchus on CXR (secondary to left atrial enlargement) 3. Persistent cough/hoarse voice (secondary to left atrial enlargement compressing recurrent laryngeal nerve) 4. Loud 1st heart sound 5. Opening snap after S2 best heard at apex 6. Low-pitched diastolic rumble best heard at apex

Question 392

What diagnosis is characterized by manometry that demonstrates high amplitude peristaltic contractions in the setting of a lower esophageal sphincter that usually has a normal relaxation response?

Answer 392

Diffuse esophageal spasm *Since the spasms occur in episodes, positive manometric findings may be intermittent, thus making diagnosis difficult.* *The esophagogram is frequently normal, although the classic corkscrew esophagus is seen occasionally.*

Question 393

New-onset neurological deficits, occipital headache, and past medical history of vascular disease, hypertension, and atrial fibrillation raise suspicion for what?

Answer 393

Stroke

Question 394

What should be the first step in evaluating an elderly patient with iron deficiency anemia?

Answer 394

Colonoscopy ## Footnote *The most common cause of iron deficiency anemia in an elderly patient is gastrointestinal blood loss.*

Question 395

Classically, papillary muscle rupture is associated with infarction of which region of the myocardium?

Answer 395

Posteroseptal MIs due to solitary blood supply of the posterior medial papillary muscle *Though less common, it can occur with anterolateral MIs as well*

Question 396

What supplies blood to the AV node in 90% of patients?

Answer 396

The right coronary artery via the AV nodal artery ## Footnote *RCA occlusion can cause AV block and inferior MI. Thus, Inferior MI is most commonly associated with sinus bradycardia due to increased vagal tone in the first 24 hours after infarction and decreased RCA blood supply to the sinoatrial node*

Question 397

Hyperactive deep tendon reflexes, muscle cramps, and convulsions (rare) are caused by what electrolyte imbalance?

Answer 397

Hypocalcemia

Question 398

What can often present similarly to right ventricular infarction with right sided heart failure and sometimes hypotension?

Answer 398

Pulmonary thromboembolism * Hypotension usually only occurs with massive embolism. PE and right ventricular infarction can be differentiated as follows:* * Right ventricular MI: ST elevation on ECG* * PE: Sinus tachycardia, new onset right bundle branch block (RBBB) or S1Q3T3 on ECG*

Question 399

Digoxin is used to treat which arrhythmias?

Answer 399

Atrial arrhythmias *It can cause nausea, anorexia, AV block, and ventricular and supraventricular arrhythmias.*

Question 400

What diagnosis is characterized by decreased glomerular filtration in the absence of shock, proteinuria, or any other clear causes of renal dysfunction, and a failure to respond to a 1.5 liter normal saline bolus?

Answer 400

Hepatorenal syndrome (HRS) ## Footnote *This is one of the most dangerous complications of end-stage liver disease, occurring in up to 10% of patients with cirrhosis. It is thought to result from renal vasoconstriction in response to decreased total renal blood flow and vasodilatory substance synthesis. There are 2 subtypes of HRS. Type 1 is rapidly progressive; most patients die within 10 weeks without treatment. Type 2 progresses more slowly, with an average survival of 3-6 months. The most common causes of death are infection and hemorrhage. Unfortunately, no medication has consistently proven beneficial in HRS and the mortality for these patients placed on dialysis is very high. Liver transplantation is the only intervention with estalished benefit.*

Question 401

What disease is characterized as a chronic progressive disorder of unknown etiology with inflammation, fibrosis, and stricturing of medium-sized and large intrahepatic and extrahepatic bile ducts?

Answer 401

Primary sclerosing cholangitis ## Footnote *It is frequently associated with ulcerative colitis. Laboratory studies usually show unexplained elevated liver function tests in a cholestatic pattern.*

Question 402

What is the mechanism of action of sodium bicarbonate in treating overdose with a tricyclic antidepressant?

Answer 402

Sodium Bicarb reverses the prolongation of the QRS interval by increasing the extracellular sodium concentration

Question 403

What vaccination should be administered to a patient infected with hepatitis C virus?

Answer 403

Hepatitis B vaccine ## Footnote *Patients with risk factors for hepatitis B virus should be vaccinated, which is especially important in patients already infected with hepatitis C virus who are continuing their high-risk behaviors.*

Question 404

Plasma hyperosmolality with urine hypoosmolality is suggestive of what?

Answer 404

Diabetes Insipidus *The normal reaction to plasma hyperosmolality is the production of maximally concentrated urine. This is seen in psychogenic polydipsia*

Question 405

What is the most frequent cause of isolated aortic stenosis in elderly patients?

Answer 405

Age-dependent idiopathic sclerocalcific changes *These changes are common and usually have minimal hemodynamic significance, but sometimes may be severe.*

Question 406

What is the most appropriate treatment of post-ictal acidosis?

Answer 406

Observation with repeat chemistry panel after 2 hours ## Footnote *Post-ictal lactic acidosis is transient and typically resolves within 60-90 minutes. Repeat chemistry is done to see if the acidosis has resolved on its own. If it has not resolved, it is best to look for other potential causes of metabolic acidosis.*

Question 407

What diagnosis should be suspected in a patient with inflammatory bowel disease (IBD) and worsening symptoms accompanied by signs of sepsis?

Answer 407

Toxic megacolon *An abdominal radiograph should be ordered to confirm the diagnosis. The most widely used criteria to clinically diagnose toxic megacolon includes radiographic evidence of colonic distension* *_plus at least three of the following_:* 1. *Fever \>38C* 2. *Heart rate \> 120 beats/minute* 3. *Neutrophilic leukocytosis \> 10,500/mL* 4. *Anemia* *_Plus at least one of the following_:* 1. *Volume depletion* 2. *Altered sensorium* 3. *Electrolyte disturbances* 4. *Hypotension*

Question 408

Hemodynamically stable supraventricular tachycardia should be treated with what?

Answer 408

Maneuvers to increase vagal tone followed by adenosine and AV nodal blockers

Question 409

What diagnosis can have a subtle presentation and should be considered in any patient with cirrhosis and ascites accompanied by either fever or a change in mental status?

Answer 409

Spontaneous bacterial peritonitis ## Footnote *Paracentesis is the test of choice, with a positive ascites fluid culture and polymorphonuclear leukocyte level \> 250/mm³ being the main criteria for making the diagnosis.*

Question 410

Headaches, a focal neurological deficit, a solitary ring-enhancing lesion on brain CT scan, and a fluid collection in the maxillary sinus is most indicative of what?

Answer 410

Brain abscess secondary to maxillary sinusitis. Anaerobic streptococci (60-70%) and Bacteriodes species (20-40%) are the organisms most commonly responsible.

Question 411

What test is absolutely indicated in a patient with an MI who develops a cold leg?

Answer 411

An Echo *This is necessary to rule out a thrombus in the left ventricle*

Question 412

Pharyngoesophageal (Zenker's) diverticulum develops immediately above the upper esophageal sphincter by herniating posteriorly between the fibers of what muscle?

Answer 412

Cricopharyngeal muscle ## Footnote *Motor dysfunction and incoordination are responsible for the problem.*

Question 413

The majority of ventricular free wall ruptures occur after what region of infarction?

Answer 413

Anterior MI

Question 414

What is the most likely cause of urinary infection in a patient with alkaline urine?

Answer 414

Proteus species

Question 415

What is the appropriate treatment for patients with small nonbleeding esophageal varices?

Answer 415

Nonselective beta blockers (I.E. Propranolol, nadolol) ## Footnote *Prophylactic treatment with nonselective beta blockers is recommended to reduce the likelihood of progression to large varices and the risk of variceal hemorrhage. The mechanism involves decreased adrenergic tone in mesenteric arterioles that results in unopposed alpha-mediated vasoconstriction and decreased portal venous flow. Endoscopic variceal ligation can be used as an alternate primary preventive therapy in patients with contraindications to beta blocker therapy.*

Question 416

What condition is thought to be due to a deficiency of or autoantibody against a specific von willebrand factor-cleaving protease (ADAMTS-13), resulting in the accumulation of large von willebrand factor multimers and platelet aggregation?

Answer 416

Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) ## Footnote *TTP-HUS is fatal in 80% of cases if appropriate therapy is not promptly instituted, so a high degree of clinical suspicion is necessary. Plasmapheresis (plasma exchange) is the treatment of choice and should be started as soon as possible. Plasmapheresis removes the offending autoantibodies and repletes the deficienct enzyme.*

Question 417

What happens to the A-a gradient in interstitial lung disease and why?

Answer 417

It increases due to reduced diffusing capacity and V/Q mismatch. *In restrictive lung diseases, the total lung capacity, functional residual capacity, and residual volume are all reduced. Flow volumes are also reduced but the ratio of FEV1/FVC is either normal or increased*

Question 418

What drug is useful in the initial diagnosis and management of patients with narrow-complex tachycardia, working by slowing the sinus rate, increasing atrioventricular nodal conduction delay, or causing a transient block in AV node conduction?

Answer 418

Intravenous adenosine

Question 419

What should one suspect whenever test results demonstrate a large amount of blood on urinalysis with a relative absence of RBCs on urine microscopy?

Answer 419

Myoglobinuria

Question 420

Patients with Wolf-Parkinson-White syndrome who develop atrial fibrillation with a rapid ventricular rate should be treated with what?

Answer 420

Cardioversion or antiarrhythmics like procainamide *AV nodal blockers like beta-blockers, calcium channel blockers, digoxin, and adenosine should be avoided because they can cause increased conductance through the accessory pathway*

Question 421

What vitamin/nutrient deficiency is common in patients with Sickle Cell Disease (SCD)?

Answer 421

Folic acid deficiency ## Footnote *In SCD, folate deficiency can occur due to increased red blood cell turnover and increased consumption of folate in the bone marrow. Daily folic acid supplementation is recommended in all SCD patients to correct the underlying folate deficiency.*

Question 422

Which hepatitis virus is more dangerous in pregnant women?

Answer 422

Hepatitis E virus (HEV) ## Footnote *Infection with HEV has a high rate of progression to fulminant hepatitis in pregnant women, especially in the third trimester. HEV is primarily transmitted via the fecal-oral route, not sexual contact.*

Question 423

What antithrombotic therapy is indicated in an atrial fibrillation patient with a CHADS2 score of 1?

Answer 423

Anticoagulation (warfarin or novel agents) or antiplatelet therapy (aspirin). Anticoagulation is preferred.

Question 424

What are the 4 dietary recommendations for patients with renal calculi?

Answer 424

1. Decreased dietary protein and oxalate 2. Decreased sodium intake 3. Increased fluid intake 4. Increased dietary calcium

Question 425

Patients with carcinoid syndrome are at risk of developing what vitamin deficiency?

Answer 425

Niacin ## Footnote *This occurs because of the increased formation of serotonin from tryptophan.*

Question 426

What is the first step in the treatment of right ventricular MI?

Answer 426

**IV fluid resuscitation** to increase the RV stroke volume and enhance left ventricular filling. **Nitrates are contraindicated**

Question 427

A significant decrease or absence of peristaltic waves and increased lower esophageal sphincter (LES) tone are characteristic of what?

Answer 427

Achalasia

Question 428

The following signs/symptoms are characteristic of what electrolyte abnormality? 1. Constipation 2. Anorexia 3. Weakness 4. Polyuria 5. Neurologic symptoms

Answer 428

Hypercalcemia ## Footnote *Symptoms are more likely to occur when serum calcium \>12mg/dL.*

Question 429

What 2 organisms are the most frequent causes of sexually-transmitted acute epididymitis?

Answer 429

Chlamydia and Gonococcus

Question 430

The results of which function tests should be monitored in a patient taking amiodarone?

Answer 430

1. Pulmonary function tests 2. Thyroid function tests 3. Liver functions tests *Amiodarone is associated with pulmonary fibrosis, hepatotoxicity, and thyroid dysfunction*

Question 431

What is the treatment of choice for Dressler's syndrome?

Answer 431

NSAIDs *Anticoagulation should be avoided to prevent the development of a hemorrhagic pericardial effusion*

Question 432

What kind of shock is characterized by: 1. Increased systemic vascular resistance 2. Decreased right atrial pressure 3. Decreased pulmonary capillary wedge pressure 4. Decreased cardiac index (pump function) 5. Decreased mixed venous oxygen saturation

Answer 432

Hypovolemic shock

Question 433

Calcium oxalate crystals are seen in patients with what poisoning?

Answer 433

Ethylene glycol poisoning

Question 434

What is the first-line medical therapy for hypertrophic cardiomyopathy?

Answer 434

Beta-blockers (works by promoting diastolic relaxation) *A cardiac acting calcium channel blocker such as diltiazem can be used in patients that cannot tolerate a beta-blocker*.

Question 435

All patients suspected of having Zollinger-Ellison syndrome should have what test done?

Answer 435

Fasting serum gastrin levels ## Footnote *A serum gastrin value \> 1000pg/mL is diagnostic of the disorder. In addition, measurement of gastric pH levels on a single specimen is important to exclude the possibility of secondary hypergastrinemia due to achlorhydria. Patients with non-diagnostic fasting serum gastrin levels should have a secretin stimulation test done.*

Question 436

What is necessary for the definitive diagnosis of Aortic stenosis?

Answer 436

Echocardiogram

Question 437

In order for a TIA to cause syncope it must affect the posterior circulation and what?

Answer 437

The brainstem

Question 438

The clinical presentation of anemia, painless gastrointestinal bleeding, and murmur of aortic stenosis is most consistent with the presence of what pathology?

Answer 438

Angiodysplasia (arteriovenous malformation) of the gastrointestinal tract ## Footnote *They are usually seen in patients age \>60 years and can occur throughout the gastrointestinal tract including colon, small intestine, and stomach.*

Question 439

Dilated cardiomyopathy can be seen following viral myocarditis, particularly after infection with what?

Answer 439

Coxsackievirus B

Question 440

What is the treatment of pharyngoesophageal (Zenker's) diverticulum?

Answer 440

Surgical treatment including excision, and frequently cricopharyngeal myotomy

Question 441

What is indicated by the presence of leukocyte esterases and nitrites in the urine, detected using a urine dipstick test?

Answer 441

1. Positive leukocyte esterase signifies significant pyuria (defined as the presence of 6-10 or more neutrophils per high power field of unspun, voided mid-stream urine) 2. Positive nitrites indicate the presence of E Coli.

Question 442

When do you give potassium to a patient in DKA?

Answer 442

1. Hyperkalemic patients should recieve IV fluids and insulin, and once potassium levels drop below 4.5mEq/L, they should start recieving K⁺ too 2. Normo or hypokalemic patients should recieve K+ right away with IV fluids and insulin *(Remember that hyperkalemic, normokalemic, and hypokalemic patients all have reduced total body potassium due to extracellular shift and subsequent gastrointestinal loss)*

Question 443

What is the ideal antibiotic regimen for patients less than 3 months of age who have suspected acute bacterial meningitis?

Answer 443

IV Cefotaxime + Ampicillin *Ceftriaxone can be used in neonates instead of Cefotaxime but it has been associated with biliary sludging, so Cefotaxime is preferred*

Question 444

What arrhythmia is most specific for digitalis toxicity?

Answer 444

Atrial tacchycardia with AV block *Since it is rare for ectopy and AV block to occur simultaneously, when they do, the combination is fairly specific for digitalis toxicity*

Question 445

What is the pattern of inheritence of Glucose-6-phosphate dehydrogenase deficiency?

Answer 445

X-linked recessive ## Footnote *More common in African-American men.*

Question 446

What is the serum ascities albumin gradient (SAAG) in portal hypertension?

Answer 446

SAAG _\>_ 1.1 g/dL *The SAAG is used to distinguish between portal hypertension and other causes of ascites. The SAAG is calculated by subtracting the ascites albumen concentration from the serum albumin concentration.* *A difference of 1.1 g/dl or greater is 95% accurate in diagnosing a transudative process consistent with portal hypertension.*

Question 447

Which three antiviral medications can shorten the duration of symptoms and decrease the risk of post-herpetic neuralgia when administered in the first few days of a shingles outbreak?

Answer 447

1. Acyclovir 2. Valacyclovir 3. Famciclovir

Question 448

What size induration is considered a positive PPD test in an HIV positive patient?

Answer 448

\>5 mm within 48-72 hours of intradermal injection of 5 tuberculin units

Question 449

What test can be performed to confirm the diagnosis of vasovagal syncope?

Answer 449

Upright tilt table test

Question 450

What kind of diet predisposes to renal stone formation?

Answer 450

High protein diet ## Footnote *This is associated with mainly calcium stones.*

Question 451

How might a patient's BUN/creatinine ratio change in the setting of gastrointestinal bleeding?

Answer 451

Increased BUN/creatinine ratio ## Footnote *This occurs due to the breakdown of hemoglobin in the gastrointestinal tract with resultant urea absorption. Systemic steroids can also increase the BUN/creatinine ratio.*

Question 452

Back pain and symptoms of hemodynamic compromise should raise suspicion for what?

Answer 452

Retroperitoneal hematoma

Question 453

What glomerulopathy is most commonly associated with HIV?

Answer 453

Collapsing focal and segmental glomerulosclerosis ## Footnote *Another name for this disease is HIV-related nephropathy. Typical presentation of focal segmental glomerulosclerosis includes nephrotic range proteinuria, azotemia, and normal sized kidneys. It is interesting to note that focal segmental glomerulosclerosis can be manifested even if all the markers of HIV (CD4 count, viral load) are normal. For an unknown reason, the disease is more prevalent among blacks than among other ethnic groups.*

Question 454

What are the clinical features of drug-induced interstitial nephritis?

Answer 454

Fever, rash, arthralgias, peripheral eosinophilia, hematuria, sterile pyuria and eosinophiluria, WBC casts in urine but rarely RBC casts.

Question 455

What is the most likely cause of dyspnea in a patient with elevated pro-brain natriuretic peptide (proBNP)?

Answer 455

Congestive heart failure *Elevated BNP levels and an audible S3 are both signs of increased cardiac filling pressures.*

Question 456

What is the treatment of lower extremity edema that is caused by chronic venous insufficiency?

Answer 456

1. Leg elevation 2. Compression stockings 3. Intermittent pneumatic compression dressings

Question 457

What is a statistical method used to compare the means of two groups of subjects?

Answer 457

Two-sample t-test

Question 458

Epigastric pain that improves with eating is typical of what?

Answer 458

Duodenal ulcer

Question 459

Liver biopsy showing mallory bodies, infiltration by neutrophils, liver cell necrosis, and a perivenular distribution of inflammation are all suggestive of what diagnosis?

Answer 459

Alcohol hepatitis ## Footnote *Fatty liver (steatosis), alcoholic hepatitis, and early fibrosis of the liver can be reversible with the cessation of alcohol intake. True cirrhosis (with regenerative nodules) is irreversible, regardless of alcohol abstinence.*

Question 460

The following findings are consistent with what diagnosis? 1. Medullary thyroid cancer 2. Pheochromocytoma 3. Parathyroid hyperplasia

Answer 460

Multiple Endocrine Neoplasia (MEN) type 2A ## Footnote *Medullary thyroid cancer (\>90%), Pheochromocytoma (40-50%), Parathyroid hyperplasia (10-20%).*

Question 461

The following signs/symptoms are characteristic of what diagnosis? 1. Severe jaundice 2. Fever 3. Right upper-quandrant pain 4. Leukocytosis

Answer 461

Acute bacterial cholangitis

Question 462

What is the treatment for Wilson's disease?

Answer 462

1. Copper chelators like d-penicillamine or trientine 2. Oral Zinc ## Footnote *Treatment must be adhered to for the patient's lifetime and focuses on removing accumulated copper in the tissues and preventing re-accumulation. First line medications include copper chelators. Oral zinc is also recommended as it prevents copper absorption. Liver transplantation may be the only option for those with fulminant hepatic failure or decompensated liver disease that does not respond to pharmacotherapy.*

Question 463

Viral arthritis is distinguished from rheumatoid arthritis and other causes of symmetric arthritis by what?

Answer 463

1. Acute onset 2. Lack of inflammatory markers 3. Resolution within two months

Question 464

What type of renal stones are most commonly seen in patients with unusually low urine pH levels?

Answer 464

Uric acid stones ## Footnote *These are radiolucent stones, but they can be seen on ultrasound and computed tomography (CT) scans. Alkalinization of urine to pH \>6.5 with oral potassium bicarbonate or potassium citrate is the treatment of choice.*

Question 465

Smudge cells are highly characteristic of what?

Answer 465

Chronic lymphocytic leukemia

Question 466

What are some electrolyte abnormalities that thiazide diuretics can cause?

Answer 466

1. Hyponatremia 2. Hypokalemia 3. Hypercalcemia

Question 467

Variant (Prinzmetal's) angina is a vasospastic disorder that typically occurs in what patient population?

Answer 467

Young female smokers *Chest pain usually occurs in the middle of the night, and episodes are associated with transient ST elevations on ECG*

Question 468

Renal vein thrombosis can occur in any form of nephrotic syndrome but which is most common?

Answer 468

Membranous glomerulonephritis

Question 469

What is the drug regimen of choice for chemoprophylaxis of TB

Answer 469

Isoniazid + Pyridioxine for 9 months (pyridoxine is to prevent neuropathy caused by Isoniazid)

Question 470

A dilated esophagus with distal narrowing on barium swallow, and lower esophageal sphincter abnormalities on manometry are characteristic of what diagnosis?

Answer 470

Achalasia ## Footnote *Esophageal malignancy at the esophageal-gastric junction can mimic achalasia and should be excluded with endoscopy before starting treatment for achalasia.*

Question 471

Periodic abdominal pain that is not relieved by H2 blockers and proton pump inhibitors in the setting of an endoscopy showing multiple duodenal ulcers and possibly a jejunal ulcer is suggestive of what diagnosis?

Answer 471

Zollinger-Ellison syndrome

Question 472

What is the most useful lab test in assessing for coronary re-occlusion after an MI?

Answer 472

CK-MB *It typically returns to normal levels within 1-2 days, whereas troponin T takes up to 10 days to return to normal after an MI, making elevations difficult to interpret in this sort of scenario.*

Question 473

By what mechanism do nitrates relieve chest pain?

Answer 473

They cause venodilation, which reduces cardiac preload and thus decreases myocardial oxygen demand

Question 474

What is the treatment for uremic pericarditis in patients with chronic renal failure?

Answer 474

Hemodialysis

Question 475

What is treatment for cat-scratch disease has proven effective

Answer 475

5 day course of Azithromycin

Question 476

What glomerulopathy is caused by persistent activation of the alternative complement pathway?

Answer 476

Membranoproliferative glomerulonephritis (MPGN) type 2 ## Footnote *Dense intramembranous deposits that stain for C3 is a characteristic microscopic finding for MPGN type 2 (also called dense deposit disease). This condition is unique among glomerulopathies, because it is caused by IgG antibodies (termed C3 nephritis factor) directed against C3 convertase of the alternative complement pathway. The antibodies reacting with C3 convertase lead to persistent complement activation and kidney damage. MPGN type I is the most common by far and is caused by immune complexes depositing in the kidney. MPGN type 3 is very rare, and is characterized by a mixture of subepithelial deposits and the typical pathological findings of type 1 disease.*

Question 477

What is the drug of choice in treating resting tremor as in Parkinson's?

Answer 477

Anticholinergic drugs such as Benztropine

Question 478

Outflow obstruction in hypertrophic cardiomyopathy is caused by what?

Answer 478

Septal hypertrophy and systolic anterior motion (SAM) of the mitral valve

Question 479

What reflex changes are common with old age?

Answer 479

Absent or decreased achilles tendon reflex can be a normal finding in elderly patients

Question 480

What syndrome is characterized as a rare, autosomal dominant disorder due to a single mutation of a tumor suppressor gene on chromosome 11?

Answer 480

Multiple endocrine neoplasia (MEN) type I ## Footnote *It is due to a single mutation of the MEN I tumor suppressor gene on chromosome 11. MEN I typically causes a predisposition to parathyroid, pituitary, and pancreatic tumors.*

Question 481

What is the treatment of choice for hyperthyroidism-related tachysystolic atrial fibrillation?

Answer 481

Beta-blocker

Question 482

What effect on white blood cells do glucocorticoids have?

Answer 482

1. They cause an increase in neutrophils by increasing the bone marrow release and mobilizing the marginated neutrophil pool 2. They cause a decrease in Eosinophils 3. They cause a decrease in lymphocytes

Question 483

Fever, joint pain, and rash starting on face and spreading to the body is typical of what?

Answer 483

Rubella

Question 484

What should you always consider in a young patient with chronic diarrhea, abdominal pain and weight loss?

Answer 484

Crohn's Disease

Question 485

Inferior wall MI is usually due to occlusion of what?

Answer 485

Right coronary artery (80% of cases) *Left circumflex occlusion would be the cause in 20% of cases*

Question 486

What is the most common cause of nephrotic syndrome in children?

Answer 486

Minimal change disease