Internal Medicine: UWorld Flashcards
A patient presents with the symptoms below. What is the patient suffering from?
- Non-inflammatory edema of the face, limbs, genitalia
- Laryngeal edema
- Edema of the bowels resulting in colicky abdominal pain
Angioedema
What is the drug of choice in patients who present with hypertension and a benign essential tremor?
Propranolol
Propranolol is a non-selective beta-blocker that is effective in reducing the tremor probably by blocking beta-2 receptors
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?
Pericardial effusion
What is the treatment for asymptomatic pre-ventricular contractions (PVCs) that develop in a patient following an MI?
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
What is the most common cause of nephrotic syndrome in children?
Minimal change disease
What are the first 2 steps in management of a patient with cirrhosis?
- Screening endoscopy
- 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.
By what mechanism do nitrates relieve chest pain?
They cause venodilation, which reduces cardiac preload and thus decreases myocardial oxygen demand
What test can be performed to confirm the diagnosis of vasovagal syncope?
Upright tilt table test
How is a pancreatic pseudocyst best diagnosed?
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.
Nearly 90% of patients with essential mixed cryoglobulinemia have what disease?
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.
Neck pain, fever, trismus (inability to open the mouth normally), and limited cervical extension could be indicative of what?
Retropharyngeal abscess
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?
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.
What is the ideal antibiotic regimen for patients less than 3 months of age who have suspected acute bacterial meningitis?
IV Cefotaxime + Ampicillin
Ceftriaxone can be used in neonates instead of Cefotaxime but it has been associated with biliary sludging, so Cefotaxime is preferred
What is indicated by the presence of leukocyte esterases and nitrites in the urine, detected using a urine dipstick test?
- 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)
- Positive nitrites indicate the presence of E Coli.
The results of which function tests should be monitored in a patient taking amiodarone?
- Pulmonary function tests
- Thyroid function tests
- Liver functions tests
Amiodarone is associated with pulmonary fibrosis, hepatotoxicity, and thyroid dysfunction
A significant decrease or absence of peristaltic waves and increased lower esophageal sphincter (LES) tone are characteristic of what?
Achalasia
Patients with carcinoid syndrome are at risk of developing what vitamin deficiency?
Niacin
This occurs because of the increased formation of serotonin from tryptophan.
Which hepatitis virus is more dangerous in pregnant women?
Hepatitis E virus (HEV)
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.
What should be performed in all post-operative patients with oliguria and acute renal failure?
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.
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?
Polymyalgia Rheumatica
What jaundice-causing complication can occur following a prolonged surgery characterized by hypotension, extensive blood loss into tissues, and massive blood replacement?
Postoperative cholestasis
What should one suspect whenever test results demonstrate a large amount of blood on urinalysis with a relative absence of RBCs on urine microscopy?
Myoglobinuria
The following findings are consistent with what diagnosis?
- Fatigue
- Itching
- Jaundice
- Weightloss
- Elevated alkaline phosphatase levels
- Positive antimitochondrial antibody test
Primary biliary cirrhosis
Heinz bodies on peripheral blood smear is suggestive of what diagnosis?
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.
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?
A brain abscess
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?
Primary sclerosing cholangitis
It is frequently associated with ulcerative colitis. Laboratory studies usually show unexplained elevated liver function tests in a cholestatic pattern.
What is the most commonly used tumor marker for pancreatic cancer?
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.
What syndrome is characterized as an autosomal dominant disorder caused by germline mutations involving the RET proto-oncogene located on chromosome 10?
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.
What can often present similarly to right ventricular infarction with right sided heart failure and sometimes hypotension?
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*
What should be the first step in evaluating an elderly patient with iron deficiency anemia?
Colonoscopy
The most common cause of iron deficiency anemia in an elderly patient is gastrointestinal blood loss.
What is the treatment of choice for anemia secondary to end stage renal disease?
Recombinant erythropoietin
The major cause of anemia in patients with end stage renal disease is deficiency of erythropoietin.
Stored red blood cells gradually leak what substance?
Potassium
Stored red blood cells gradually lose intracellular potassium to the surrounding solution. This mechanism has the potential to cause hyperkalemia.
What diagnosis is suggested by a toxic appearance, fever, nausea, vomiting, flank pain, dysuria, and costovertebral tenderness?
Acute pyelonephritis
Urinalysis shows bacteriuria and pyuria. Urine culture reveals greater than 10,000 colonies/mL.
What is a simple and effective way to reduce the formation of decubitus ulcers?
Patient repositioning every 2 hours
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?
Nitroglycerin
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.
D-xylose test is used to assess what?
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.
Which autoimmune condition is characterized by non-caseating granulomas?
Crohn’s disease
This is not a feature of ulcerative colitis.
- Cyclophosphamide is an alkylating agent frequently used as an immunosuppressant in what conditions?
- What are some serious side effects?
- Systemic Lupus Erythematosus, vasculitis, and certain cancers
- Acute hemorrhagic cystitis, bladder carcinoma, sterility, and myelosuppression
(Hemorrhagic cystitis and bladder cancer are caused by a bladder-toxic metabolite of cyclophosphamide called acrolein)
Hemodynamically unstable ventricular tachycardia should be treated with what?
Emergent DC cardioversion
A barium swallow revealing a “corkscrew” esophagus is suggestive of what diagnosis?
Diffuse esophageal spasm
The esophagogram is frequently normal, although the classic corkscrew esophagus is seen occasionally.
Declining serum transaminase levels in the setting of a rising prothrombin time is suggestive of what?
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.
Accelerated atherosclerosis is seen in what renal condition?
Nephrotic syndrome
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.
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?
Henoch-Schonlein purpura
Serum complement levels are normal in this condition.
What are the most sensitive and specific tests for the diagnosis of acute pancreatitis?
Serum amylase and lipase levels
What 2 organisms are most commonly cultured from the ascites fluid of a patient with spontaneous bacterial peritonitis?
- E. Coli
- Klebsiella
Enteric organisms are the most common. Empiric therapy is generally with a 3rd generation cephalosporin.
What is the treatment of choice for premature atrial contractions?
Nothing/Observation
PACs are benign and neither require any treatment or follow-up
A prolonged QT interval suggests what?
Tachyarrhythmia
What are the two most common pathologies seen in analgesic nephropathy?
- Papillary necrosis
- 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.
What pharmacological agent is used in the treatment of active esophageal variceal bleeding but has no role in primary prophylaxis of variceal hemorrhage?
Octreotide
This is a long-acting analog of somatostatin that causes splanchinc vasoconstriction and reduced portal blood flow by inhibiting the release of glucagon.
What test has replaced the lactose tolerance test?
Lactose hydrogen breath test
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.
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?
The side effect is explained by prostaglanding-induced peripheral vasodilation and can be reduced by low-dose aspirin
What is the first line medical treatment for idiopathic benign intracranial hypertension?
Acetazolamide
It inhibits choroid plexus carbonic anhydrase and thus reduces CSF production and intracranial hypertension
What is the most common side effect and most serious side effect of antithyroid drug therapy?
- Most common: Allergic reaction (2% of patients)
- Most serious: Agranulocytosis (0.3% of patients)
What is Flecainide typically used to treat?
Ventricular arrhythmias and supraventricular tachycardias such as atrial fibrillation.
Megacolon/megaesophagus and cardiac disease are the two primary manifestations of what?
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
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?
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.
What is the most likely diagnosis in a patient with massive increases in AST and ALT a day after presenting with shock?
Ischemic hepatic injury (shock liver)
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.
Thrombotic thrombocytopenic purpura (TTP) is due to decreased activity of what?
ADAMTS-13
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.
Hypertensive emergency is defined as marked, severe hypertension associated with what (more specific than end-organ damage)?
Malignant hypertension (retinal hemorrhages, exudates, and/or papilledema) or hypertensive encephalopathy (cerebral edema)
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?
Citrate
Citrate is an anticoagulant that is added to stored blood. Citrate chelates calcium and magnesium and may reduce their plasma levels, causing paresthesias.
What is the post-exposure prophylaxis for hepatitis B in an unvaccinated individual?
Hepatitis B vaccine + Hepatitis B immune globulin
This should be administered as soon as possible.
What antihypertensive class can worsen cardiac ischemia?
Dihydropyridine calcium channel blockers
They cause peripheral vasodilation and reflex tachycardia
Winter’s Formula
PaCO2 = 1.5 (HCO3-) + 8
Winter’s formula can be used to calculate the expected PCO2 during respiratory compensation for a primary metabolic acidosis.
What helps differentiate between liver and cardiac causes of lower extremity edema?
Hepato-jugular reflex is positive in cardiac etiologies
What is the most appropriate empiric antibiotic regimen for a patient >55 years old with suspected acute bacterial meningitis?
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
What is the first step in managing a patient with atrial fibrillation with rapid ventricular response?
Rate control with a beta-blocker or a calcium channel blocker
Immediate synchronized electrical cardioversion is indicated in hemodynamically unstable patients with rapid atrial fibrillation
Positive anti-thyroperoxidase (TPO) antibodies with an enlarged rubbery goiter is virtually diagnostice of what?
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.
What is the cause of hypoxia in a patient with pneumonia?
Alveolar and interstitial inflammation which causes areas of V/Q mismatch. This manifests as an increase in the alveolar-arterial oxygen gradient.
What is the most important contributor to edema in heart failure patients?
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
In general, what is the best antibiotic for infectious diarrhea?
Ciprofloxacin
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.
What effect does squatting have on hemodynamics?
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
The following signs/symptoms are characteristic of what diagnosis?
- Flushing
- Diarrhea
- Wheezing
Carcinoid syndrome
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.
By what mechanism does transudative ascites occur?
Increased hydrostatic pressure
What is the treatment for an amebic liver abscess?
Oral metronidazole
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.
The following findings are consistent with what diagnosis?
- Medullary thyroid cancer
- Pheochromocytoma
- Mucosal and intestinal neuromas
- Marfanoid habitus
Multiple Endocrine Neoplasia (MEN) type 2B
What is a common cause of acute onset monoarthropathy of the knee (often in the setting of hyperparathyroidism)?
Pseudogout
What is the study of choice for diagnosis and follow-up of abdominal aortic aneurysms?
Abdominal ultrasound
It has nearly 100% sensitivity and specificity for this condition.
What is the inheritance pattern of Crigler-Najjar syndrome?
Autosomal recessive
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.
What is the initial investigation of choice for suspected acalculous cholecystitis
Ultrasonogram, which shows signs of acute cholecystitis and no gallstones; however, CT scan and HIDA scans are more sensitive and specific for the diagnosis.
What is the most appropriate initial treatment for decompensated heart failure?
IV diuretics
They provide symptomatic benefits to patients with decompensated heart failure
What is the most common cause of secondary hypertension?
Renal artery stenosis
Associated with a continuous periumbilical murmur on physical exam.
Aortic stenosis in a young individual is usually the result of what?
A congenitally bicuspid aortic valve.
The strongest predictors of abdominal aortic aneurysm expansion and rupture are what?
- Larger aneurysm diameter
- Current cigarette smoking
How is the diagnosis of achalasia made?
- Barium swallow
- Manometry
- Endoscopy
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.
What is recommended for all patients with unexplained gross hematuria or with microscopic hematuria and other risk factors for bladder cancer?
Cystoscopy
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.
What is the first treatment of choice in patients with symptomatic sinus bradycardia who are hemodynamically unstable?
IV epinephrine
Normal amounts of total urinary coproporphyrin composed of over 80% coproporphyrin I is a finding suggestive of what diagnosis?
Dubin-Johnson Syndrome
Normal individuals have urinary coproporphyrin composed primarily (80%) of coproporphyrin III.
Worsening post-prandial pain that leads to avoidance of food and a resultant weight loss is characteristic of what?
Chronic mesenteric ischemia due to occlusion (atherosclerosis) of visceral arteries (abdominal angina)
What is important in treating patients with right heart failure secondary to right ventricular infarction?
IV fluids and avoidance of preload reducing medications such as nitrates and diuretics
These patients are preload dependent and dropping preload can be catastrophic
- What is the name of the triad of hypotension, distended neck veins, and muffled heart sounds?
- What does this triad indicate?
- Beck’s Triad
- Cardiac Tamponade
- Bloody diarrhea + abdominal tenderness - fever is most suggestive of what?
- Bloody diarrhea +/- abdominal tenderness + fever is most suggestive of what?
- Infection with Enterohemorrhagic E. Coli (EHEC)
- Shigella, Slamonella, and Campylobacter
What is the leading cause of end stage renal disease in the United States?
Diabetic nephropathy
Diabetic nephropathy is characterized by increased extracellular matrix, basement membrane thickening, mesangial expansion, and fibrosis.
An important complication of nephrotic syndrome is renal vein thrombosis. How does it present?
- Sudden onset abdominal pain
- Fever
- Hematuria
What is the fluid of choice to be administered to a hypotensive, dehydrated patient with Diabetes Insipidus?
Normal saline
Hypotonic fluids can be started when the intravascular volume improves.
Hypogonadism, arthropathy, diabetes, and hepatomegaly in the setting of dilated cardiomyopathy, heart failure or cardiac conduction abnormalites is characteristic of what?
Hereditary hemochromatosis
Abnormal iron deposition in various organs, leading to multisystem end-organ damage.
Paroxysmal, lightning-like pain on the face is usually due to what?
Trigeminal neuralgia
Fever, painful enlargement of the testes, and irritative voiding symptoms are characteristics of what diagnosis?
Acute epididymitis
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.
Clear lung fields, hypotension, and jugular venous distension in the setting of an inferior wall MI are suggestive of what?
Right ventricular infarct
What is used to treat low fibrinogen states?
Cryoprecipitate
Cryoprecipitate contains fibrinogen.
What disease is characterized as a necrotizing inflammation of medium-sized arteries and occasionally the small muscular arteries?
Polyarteritis nodosa (PAN)
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.
a seizure, as compared to a syncopal episode, is likely to be associated with what?
- Confusion following episode of loss of consciousness
- Bitten tongue after episode
- Sore muscles after episode
What is the diagnostic test for diffuse esophageal spasm (DES)?
Manometry
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.
What two immunosuppressants are implicated in causing optic neuritis?
Ethambutol and Hydroxychloroquine
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).
Granulomatosis with polyangiitis (Wegener’s Granulomatosis)
Multiple episodes of thrombosis in a young patient without a clear precipitating factor should raise concern for hypercoagulability due to what?
Genetic defect (I.E. Deficiencies of Protein C, Protein S, or Antithrombin III)
In an elderly patient, this would be more suggestive of a primary malignancy.
What is the first step in the initial ventilator management of ARDS?
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.
What do ethanol and sedative withdrawals cause that opioid withdrawal does not?
Seizures
In patients with preexisting heart disease, what hemoglobin level should be maintained?
_>_10g/L (or hematocrit _>_30%)
What drug class is recommended as first-line therapy for controlling anginal symptoms and improving exercise tolerance in stable angina pectoris?
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.
Zollinger-Ellison syndrome is associated with which Multiple Endocrine Neoplasia (MEN) syndrome?
MEN type I
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.
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)
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
What organism causes amebic liver cysts?
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.
An acute, severe presentation of endocarditis in a patient with previously normal heart valves is suggestive of which bacteria?
Staph Aureus
Holosystolic murmur that increases on inspiration is indicative of what?
Tricuspid regurgitation
All patients with acute cocaine toxicity and myocardial ischemia should be treated initially with supplemental oxygen and what?
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.
The following findings are consistent with what diagnosis?
- Diarrhea
- Hypokalemia resulting in leg cramps
- Decreased amount of acid in the stomach
- Dehydration
- Abdominal pain and cramping
- Weightloss
- Facial flushing and redness
Vasoactive peptide adenoma (VIPoma)
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.
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?
Glucose-6-phosphate dehydrogenase (G6PD) deficiency
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.
Epigastric pain that worsens with eating is typical of what
Gastric ulcer
What are the 6 most common kinds of nephrotic syndrome?
- Focal segmental glomerulosclerosis
- Minimal change disease
- Membranous nephropathy
- Diabetes
- Primary amyloidosis
- IgA nephropathy
In no specific order.
What plasma measure has recently become a useful laboratory test to distinguish between CHF and other causes of dyspnea?
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.
What is the most common cause of folic acid deficiency?
Nutritional (I.E. poor diet or alcoholism)
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).
Quinidine is used to treat what?
Atrial arrhythmias
Side effects include diarrhea, tinnitus, QT prolongation, torsades de pointes, hemolytic anemia and thrombocytopenia
What is the most sensitive and specific imaging study to detect gallstones?
Abdominal ultrasound
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.
What should be high on the differential of an otherwise young, healthy patient who develops CHF?
Myocarditis
Viral infection, especially with Coxsackie B virus, is the most common cause.
What is a major cause of chronic diarrhea in HIV-infected patients with CD4 counts < 180 cells/mm3?
Cryptosporidium parvum
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.
When can the MMR vaccine be administered to to an HIV patient?
When CD4 count is >200/micro-L and there is no history or evidence of an AIDS-defining illness
Asymetrically elevated blood pressure in the right arm or the arms greater than legs is suggestive of what?
Coarctation of the aorta
What segment of colon is most commonly involved in ischemic colitis?
The splenic flexure
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.
What criteria differentiates mild-moderate clostridium difficile colitis from severe clostridium difficile colitis?
Mild-moderate:
- WBC < 15,000
- Creatinine < 1.5x baseline
Severe:
- WBC > 15,000
- Creatinine > 1.5x baseline
Jugular venous distension on physical exam and right bundle branch block on ECG in the setting of hypotension are strongly indicative of what?
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
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?
Pancreatic cancer
Most (60-70%) of pancreatic cancers originate in the head of the pancreas.
What renal manifestation of chronic hepatitis C is most common?
Membranoproliferative glomerulonephritis
A delta wave is an upsloping just before the QRS complex that occurs in patients with what?
An accessory conduction pathway like in Wolf-Parkinson-White syndrome
What antihypertensive is used to treat acute heart failure and what antihypertensive is contraindicated?
- ACE inhibitors reduce afterload and are used to treat acute heart failure
- Beta-blockers are contraindicated because they decrease myocardial contractility and exacerbate the already decreased ejection fraction
What is the most frequent origin of the ectopic foci that cause atrial fibrillation?
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
Isolated systolic hypertension (ISH) is an important cause of hypertension in elderly patients that is caused by what?
Decreased elasticity of the arterial wall
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
What is the likely diagnosis in a patient younger than 30 years old with unexplained chronic hepatitis?
Wilson’s disease
The presence of low serum ceruloplasmin and increased urinary copper excretion or Kayser-Fleischer rings confirms the diagnosis.
Cochlear dysfunction is a side effect of what two immunosuppressants that are often used to treat testicular, ovarian, and bladder cancers?
Cisplatin and Carboplatin
What are the 6 criteria used to establish the diagnosis of osteoarthritis?
- Age > 50
- Crepitus
- Bony enlargement
- Bony tenderness
- Lack of warmth
- Minimal or no morning stiffness
If patient meets 3 or more criteria, the specificity for OA is 69% and the sensitivity is 95%
What is the test of choice for confirming the diagnosis of Zenker’s diverticulum?
Contrast esophagram
This will clearly show the diverticulum.
What is the drug of choice for treating a patient with suspected aspiration pneumonia (recent stroke, history of unconciousness, heavy alcohol user, recent sedation)?
Clindamycin
What disease is primary sclerosing cholangitis frequently associated with?
Ulcerative colitis
How might increased production of stomach acid lead to malabsorption?
Inactivation of pancreatic enzymes
Malabsorption may occur in patients with Zollinger-Ellison syndrome.
Which nephrotic syndrome has an association with obesity, heroin use, and HIV and accounts for >50% of nephrotic syndromes in African Americans?
Focal Segmental Glomerulosclerosis
What protein is defective in hereditary spherocytosis?
Spectrin
This is the protein that provides scaffolding for red blood cells. This is an autosomal dominant disorder.
Serum Alpha-fetoprotein (AFP) is elevated in patients with what kind of cancer?
Hepatocellular carcinoma
What is the treatment of choice for Polymyalgia Rheumatica in the presence of symptoms of Temporal Arteritis?
Emergent High-dose Prednisone to prevent vision loss while a temporal artery biopsy is performed to confirm diagnosis of Temporal (Giant cell) Arteritis
What is the pathology of angioedema?
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.
Which drug classes confer a survival benefit in CHF?
- ACE inhibitors
- ARBs
- Beta-blockers
- Spironolactone
Digoxin and Furosemide can reduce CHF symptoms and hopitalizations but they do not improve survival
Multiple episodes of thrombosis in an older patient without a clear precipitating factor should raise concern for hypercoagulability due to what?
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).
What is the inheritance pattern of hereditary spherocytosis?
Autosomal dominant
It results from a disorder of spectrin, the protein that provides scaffolding for red blood cells.
Blood at the beginning of urination typically indicates a lesion where?
In the urethra
Such as in urethritis.
Metformin should not be given to a patient with what 3 conditions?
- Renal failure
- Hepatic failure
- Sepsis
Mixed cryoglobulinemia is most commonly due to what?
Hepatitis C
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.
What is the most common cause of death in dialysis patients?
Cardiovascular disease
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).
What is the most important risk factor for bladder cancer?
Cigarette smoking
Other risk factors include occupational exposures (I.E. painters, metal workers), chronic cystitis, iatrogenic causes (I.E. Cyclophosphamide), and pelvic radiation exposure.
What drugs are considered first line agents in uncomplicated hypertension?
Thiazide diuretics and beta-blockers because of their effect in reducing cardiovascular mortality and their cost effectiveness
What diagnosis is suggested by mucopurulent urethral discharge, absent bacteriuria, and history of multiple sexual partners?
Chlamydial urethritis
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.
A prolonged QRS interval suggests what?
A bradyarrhythmia (typically bundle branch block)
Prolonged PR intervals are also often associated with bradyarrhythmias
Patient presents with ataxia, vomiting, occipital headache, gaze palsy, and facial weakness. There is no hemiparesis. What is the diagnosis?
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
What is required to diagnose atherosclerosis of the mesenteric arteries (causing abdominal angina)?
Angiography or a doppler ultrasound
Diastolic and continuous murmurs as well as loud systolic murmurs revealed on cardiac auscultation should always be investigated using what?
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
What is characterized by a narrow QRS, progressive increase in PR interval until a ventricular beat is dropped, then the sequence is repeated?
Wenckebach or Mobitz type I heart block (A type of second-degree AV block)
It is a benign arrhythmia and is transient. Unless the patient is symptomatic, it requires no treatment.
If left untreated, Patients with hyperthyroidism become at risk for what?
Rapid bone loss
Direct effects of the thyroid hormones on the bone cells eventually lead to increased osteoclastic bone resorption
Acute epididymitis in older men is usually caused by what organisms?
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.
An abdominal radiograph demonstrating air-fluid levels in the gallbladder or an ultrasound showing curvilinear gas shadowing in the gallbladder confirms what diagnosis?
Ephysematous cholecystitis
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).
The most common site of hypertensive hemorrhage is where?
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
What renal side-effect can occur with high-dose parenteral acyclovir therapy?
Crystalluria with renal tubular obstruction
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.
What is considered the single most important test to assess the function of the liver?
Prothrombin time (PT)
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.
What must be monitored closely in patients taking aminoglycosides?
Renal function
Aminoglycosides are antibiotics used to treat serious gram-negative infections. They are potentially nephrotoxic.
Hypertension, hypernatremia, hypokalemia, metabolic alkalosis, low renin levels, and high aldosterone levels is characteristic of what condition?
Conn’s Syndrome (Primary hyperaldosteronism)
What is the best diagnostic test for diverticulitis in the acute setting?
Abdominal computed tomography (CT)
This helps differentiate it from other causes of abdominal pain (I.E. Colon cancer and kidney infection).
Fever, cough, coryza, conjunctivitis, and a rash starting on face and spreading to body is typical of what?
Measles
Koplick spots are suggestive
What are the major side effects of azathioprine?
- diarrhea
- Leukopenia
- Hepatotoxicity
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.
What pharmacological agents should be avoided in variant (Prinzmetal’s) angina?
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
What is the diagnostic procedure of choice for detecting nephrolithiasis
CT scan of the abdomen because it can differentiate between calcium stones (radioopaque) and uric acid stones (radiolucent)
What is the initial treatment of both acute and chronic anal fissures?
- Dietary modification (I.E. High-fiber diet and large amounts of fluids)
- Stool softener
- Local anesthetic
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.
The redistribution of coronary blood flow to ‘non-diseased’ segments induced by dipyridamole is called what?
Coronary steal phenomenon
What are the three major treatment options of patients with Grave’s Disease?
- Radioactive iodine ablation: Preferred modality of tx in USA
- Antithyroid drug therapy
- Thyroidectomy
How is the diagnosis of peptic ulcer disease made?
Upper endoscopy
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?
Endometrial carcinoma
This develops in up to 43% of females in affected families.
Symptoms of alopecia, skin lesions, abnormal taste, and impaired wound healing are suggestive of what vitamin/nutrient deficiency?
Zinc deficiency
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.
Which antihypertensive can cause peripheral edema?
Dihydropyridine Ca-channel antagonists like amlodipine
This is due to them dilating peripheral blood vessels and not due to an allergic reaction.
Nodular glomerulosclerosis (with Kimmelstiel-Wilson nodules) is pathognomonic for what condition?
Diabetic nephropathy
The pathologic hallmark is nodular glomerulosclerosis but diffuse glomerulosclerosis is more common.
75-90% of kidney stones are composed of what?
Calcium oxalate
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.
What is the typical presentation for vertebral osteomyelitis?
- Back pain accompanied by low-grade fever and elevated ESR.
- Physical exam may demonstrate local tenderness on percussion over the affected vertebrae and paravertebral muscular spasm.
High-grade fever and chills are uncommon
The left anterior decsending coronary artery (LAD) usually supplies what?
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
Unilateral radicular pain in a dermatomal distribution is the classic presentation of what?
Disk prolapse
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.
What can be done to minimize the chance of causing contrast-induced nephropathy in a patient recieving contrast for imaging purposes?
- Use non-ionic contrast agent
- Adequate intravenous hydration
- Acetylcysteine
These all decrease the incidence of nephropathy.
What is the next step following detection of a painless, hard testicular mass with a ultrasound that is suggestive of cancer?
Radical Orchiectomy: Removal of testis + associated cord
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
Coarctation of the aorta (Check bilateral blood pressure)
What is the most effective lifestyle changes in reducing BP?
- Weight loss (in obese patients): 5-20mmHg reduction
- Physical activity: 4-9mmHg reduction
- Salt restriction: 2-8mmHg reduction
- Reduction of alcohol intake: 2-4mmHg reduction
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?
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
What is the most common cause of death in patients with acute MI?
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.
