Key facts Flashcards
Hip Clunk, assymetric leg crease
1
Q
Hip Clunk, assymetric leg crease
A
DDH - abnormal acetabular development resulting in a shallow hip socket and inadequate support of the femoral head.
2
Q
DDH (congenital hip dysplasia)
- dx
- tx
A
dx w/ ortolani and barlow
tx: pavlik harness
3
Q
Slipped capital femoral epiphysis
- dx
- tx
A
Xray: widening of joint space (“ice cream slipping off a cone”)
- tx: internal fixation with pinning
4
Q
Leg Calve perthese disease tx
A
Rest and NSAIDS - then surgery
5
Q
Juvenile idiopathic arthritis
A
autoinflammatory disease characterized by fever, joint pain, and rash.
6
Q
St Johns Wort use
A
antidepressant, anti-inflammatory, and wound-healing
- induces various P450 isozymes
- can lead to treatment failures with many medications, including hormonal contraceptives, anti-retrovirals, immunosuppressive agents, narcotics, anticoagulants, and antifungals
7
Q
long-term management of patients with chronic hypoparathyroidism:
A
Vitamin D is generally preferred over 1,25-dihydroxy vitamin D for chronic management in most patients because it is cheaper and effective
- in patients with borderline low serum calcium and high urinary calcium, as seen in the patient described in the vignette, the addition of a thiazide diuretic will not only decrease the urinary calcium, but also increase serum calcium levels.
*of note: primary hyperparathyroidism are often diagnosed incidentally - have regular f/u
8
Q
Complications in patients admitted for variceal bleeding that lead to increased mortality are:
- Treatment?
A
#1 infections, #2 hepatic encephalopathy #3 renal failure.
The most common complication is the development of an infection: TREAT WITH FQ
- urinary tract infection
- spontaneous bacterial peritonitis
- respiratory infection
- aspiration pneumonia or primary bacteremia.
9
Q
Preterm labor is defined as
A
regular uterine contractions resulting in cervical change at <37 weeks gestation.
- Intramuscular corticosteroids (eg, betamethasone) are indicated at <37 weeks gestation to decrease the risk of - neonatal respiratory distress - necrotizing enterocolitis - intraventricular hemorrhage associated with prematurity
10
Q
Preterm labor tx for gestational age
- 34-36 weeks
- 32-34 weeks
- <32 weeks
A
- 34-36 weeks: +/- betamethasone
PCN if GBS unknown - 32-34 weeks: bethamethasone
PCN if GBS unknown
tocolytics - <32 weeks: bethamethasone,
PCN if GBS unknown
tocolytics
Mg Sulfate
11
Q
VEAL CHOP
A
Cord Compression
Head Compression
Okay!
Placental utero insufficiency
12
Q
HIV management during pregnancy
A
Intrapartum
Avoid artificial ROM, fetal scalp electrode, operative vaginal delivery
- Viral load ≤1,000 copies/mL: ART + vaginal delivery (low likelihood of transmission)
- Viral load >1,000 copies/mL: ART + zidovudine + cesarean delivery (d/t higher risk for perinatal transmission during vaginal delivery)
Postpartum
Mother: continue ART
Infant (maternal viral load ≤1,000 copies/mL): zidovudine
Infant (maternal viral load >1,000 copies/mL): multidrug ART
13
Q
Breastfeeding contraindications
A
Maternal
Active untreated tuberculosis HIV infection* Herpetic breast lesions Active varicella infection Chemotherapy or radiation therapy Active substance abuse
14
Q
Salicylate toxicity
A
Salicylate crosses the blood-brain barrier and directly stimulates the medullary respiratory center (increasing respiratory rate and causing respiratory alkalosis) and the chemoreceptor trigger zone (causing nausea and vomiting).
Cochlear neurotoxicity may result in tinnitus (early symptom).
Cerebral tissue injury and neuroglycopenia lead to cerebral edema and mental status changes.
Inhibition of cellular metabolism causes lactic acidosis and hyperthermia. In severe cases, pulmonary edema, arrhythmia, and death may result.
15
Q
mixed acid-base disorder commonly noted in ____ toxicity:
A
salicylic acid toxicity:
- Primary respiratory alkalosis due to activation of medullary respiratory center: High pH of 7.5 with low PaCO2
- Anion gap (AG) metabolic acidosis due to inhibition of cellular metabolism: AG = (Na − [Cl + HCO3]) =
(normal: 8-14)
16
Q
Salicitate toxicity tx
A
alkalinization of blood and urine with sodium bicarbonate drip, supplemental glucose, and, if presentation is early (within 2 hours), activated charcoal. Dialysis may be indicated.
17
Q
Chikungunya fever
- how many days of fever before other sx?
- Which joints affected?
- What other sx?
A
high fever (up to 39 C [102 F]) for 3-5 days, followed by severe polyarthralgias.
- Arthralgias are typically bilateral and symmetric and involve distal joints more than proximal joints.
- The hands, wrists, and ankles are most commonly affected, and the pain may be severe enough to be disabling.
- Skin manifestations such as a macular or maculopapular rash
18
Q
Amniotic fluid index (AFI)
- whats nl?
- what are abnl AFI typically d/t?
A
normal levels (5-23 cm) suggest normal function of the placenta and fetal kidneys and lungs.
Abnormal AFI levels are typically due to impairments in either amniotic fluid production (eg, oligohydramnios - AFI <5) or removal (eg, polyhydramnios AFI >24).
19
Q
Preeclampsia is typically associated with fetal growth restriction and (polyhydramios/oligohydramnios) due to chronic placental insufficiency.
A
oligohydramnios due to chronic placental insufficiency.
Placental insufficiency causes shunting of fetal blood to the fetal brain and away from the fetal kidneys, decreasing fetal urinary output and causing oligohydramnios.
20
Q
AAA should be repaired when?
A
> 5 cm
or growing >0.5cm in < 1 yr
21
Q
________ are first-line pharmacotherapy for dementia-related cognitive impairment.
A
Acetylcholinesterase inhibitors (eg, donepezil, rivastigmine, galantamine)
22
Q
Acute multiple sclerosis exacerbation is treated with ____
A
corticosteroids PO or IV.
Patients with optic neuritis should receive intravenous corticosteroids as oral agents may be associated with an increased risk of recurrence.
Plasmapheresis can be used in refractory cases.
*exacerbations in pregnant patients is short-term intravenous glucocorticoids as they are generally well tolerated and are not associated with teratogenicity
23
Q
Metastatic lesions to the brain are the most common cause of brain tumors (>50%)
In the order of frequency, are:
A
lung,
breast,
melanoma,
and colon cancer.
24
Q
Perceived benefits of newer antipsychotics in treating negative symptoms are believed to result from ______ rather than true efficacy in treating core negative symptoms
A
fewer extrapyramidal side effects (ie, decreased incidence of drug-induced parkinsonism)
Psychosocial intervention, specifically social skills training, is an effective augmentation strategy to target negative symptoms.
25
positive symptoms of schizophrenia
negative symptoms
Which ones do first gen antipsychotics usually tx?
delusions, hallucinations, disorganized speech and behavior
alogia, flat affect, amotivation, social withdrawal
Antipsychotic medication is effective in treating positive symptoms, as in this patient, but does not significantly improve negative symptoms
26
_________ involves a pervasive, lifelong pattern of suspiciousness and mistrust of others.
- absence of persistent psychotic symptoms and the nonspecific nature of the distrust (generalizes to every interpersonal interaction).
Paranoid personality disorder
| - are generally paranoid and distrustful but do not have fixed delusions.
27
Under-anticoagulation can lead to worsening of thrombotic disease, and such patients should be started on _______ until a therapeutic INR (<2) is achieved with warfarin.
intravenous heparin (or subcutaneous low molecular weight heparin)
28
Scaphoid fractures are most commonly complicated by ________ and _________
nonunion and avascular necrosis in up to 10% of cases.
Scaphoid fractures can compromise the blood supply
As a result, proximal fractures of the scaphoid require longer immobilization (up to 12 weeks) for adequate healing.
Other factors that cause nonunion include delay of care, an unstable fracture fragment, and delay in surgical treatment when indicated.
29
_____ + _____ is a first-line treatment for moderate to severe alcohol use disorder. It decreases cravings and heavy drinking and can be initiated in opioid-free patients who are still drinking.
Naltrexone (a mu opioid receptor antagonist) + acamprosate (glutamate modulator)
30
Barrett esophagus is characterized by metaplastic columnar epithelium replacing normal stratified squamous epithelium; it is associated with the development of _______
What do you do if ENDOSCOPY shows:
- No dysplasia
- Low grade dysplasia
- High grade dysplasia
esophageal adenocarcinoma
ENDOSCOPY shows:
- No dysplasia: PPI and surveillance endoscopy in 3-5 years
- Low grade dysplasia: PPI and endoscopy in 6-12 months or endoscopic eradication
- High grade dysplasia: Endoscopic eradication therapy
31
About 60% of head and neck cancers are locally advanced at the time of diagnosis and are inoperable.
- tx?
chemoradiotherapy (CRT) promises superior results than chemotherapy or radiotherapy alone.
32
Patients with HIV with CD4 counts <200/mm3 are at high risk for Pneumocystis jirovecii pneumonia (PCP).
Organisms can be identified on induced sputum samples in 50%-90% of cases;
What happens if you get negative sputum analysis?
further testing if PCP is suspected
the next diagnostic test of choice is a fiberscopic bronchoscopy with bronchoalveolar lavage.
This test is highly sensitive (90%-100%) for diagnosis of PCP.
33
___________ are typically ill with high fever, dysuria, pelvic/perineal pain, and cloudy urine. Rectal examination usually reveals a warm, edematous, and very tender prostate. Urine culture usually reveals a gram-negative organism such as Escherichia coli or Proteus.
acute prostatitis
34
_______ is characterized by >3 months of dysuria and pelvic pain.
- Urine studies following prostate massage usually show pyuria (>20 leukocytes/hpf) with no microorganisms (aseptic)
Chronic prostatitis/chronic pelvic pain syndrome
uncertainty about the ideal treatment.
- Most patients receive a combination of therapies including medications for prostate enlargement (eg, alpha blockers), antibiotics, anti-inflammatories, and/or psychotherapy.
35
__________ is diagnosed when urine culture after prostate massage shows bacteriuria at a >10-fold concentration compared with urinalysis prior to prostate massage.
Chronic bacterial prostatitis
36
Early defibrillation is indicated in patients with ________
ventricular fibrillation (VF) and/or pulseless ventricular tachycardia (VT). It is ineffective in patients with asystole or pulseless electrical activity (PEA) and is contraindicated.
37
Abnormal and persistent lymphadenopathy is sometimes the first clinical manifestation of an underlying lymphoma.
Patients with localized lymphadenopathy can be observed for weeks.
- What happens if it doesn't resolve?
A biopsy should be performed if the abnormal nodes fail to resolve after that time, or earlier, if there are other signs of malignancy.
38
Tremor in patients with familial disease, usually present in the distal upper extremities and becomes much more pronounced with outstretching of the arm.
benign essential tremor
39
Resting tremor (which worsens at rest but improves with voluntary activity)
Early onset Parkinson's
40
- Sudden-onset pleuritic chest pain,
- combined with a loud P2 and
- pleural friction rub on physical examination,
- hypoxemia, and
- small pleural effusion on chest x-ray (commonly due to inflammation from pulmonary infarct),
suggests ________
acute PE
41
- fever and productive cough
- Pleuritic chest pain, hypoxemia, and
- pleural effusion on chest x-ray
suggests ________
Bronchopneumonia
42
treatment of acute asthma exacerbation
inhaled or nebulized short-acting beta agonist (albuterol)
+
inhaled ipratropium
In patients with persistent symptoms, the next step is the administration of systemic corticosteroids (eg, oral prednisone) without delay;
43
Pt has
- dysmenorrhea,
- chronic pelvic pain,
- deep dyspareunia,
- dyschezia, and
- infertility.
PE: examination findings include pain on lateral movement of the cervix;
- a fixed, immobile uterus; uterosacral nodularity; and
- adnexal masses, although examination is often normal.
Endometriosis
First-line treatment for endometriosis is with nonsteroidal anti-inflammatory drugs and combined oral contraceptives
44
Asymptomatic pituitary incidentaloma
| - what do you do?
repeat MRI of pituitary in 6-12 mo
45
measure ______ when the screening test for Cushing's syndrome (overnight dexamethasone suppression test) is positive
Plasma ACTH levels
46
_______ test is usually used in the evaluation of patients with adrenal insufficiency.
Cosyntropin
47
ECG shows regular narrow-complex tachycardia (QRS duration of 90 msec) at a rate of 175/min
- what medicine do you give?
adenosine 6mg
48
treatment of Tourette syndrome
Habit reversal therapy (HRT), a form of cognitive-behavioral therapy
second-generation antipsychotics (eg, risperidone, aripiprazole)
- reduce the frequency and intensity of tics by 60%-80%.
49
Hypertransfusion regimen can suppress the effects of chronic severe anemia and extramedullary hematopoiesis, but result in significant ___________
iron overload and resultant organ damage.
ie: in treating thalassemia major, a severe congenital hemolytic anemia.
50
When diverticulitis does not improve after 2-3 days of antibiotic therapy, what do you do?
repeat abdominopelvic CT scan is required to evaluate for complications (eg, abscess, perforation, obstruction).
Colonoscopy is contraindicated in patients with acute diverticulitis.
51
Nitroprusside is frequently used in the management of acute hypertensive emergency.
Nitroprusside is a potent vasodilator that works on both arterial and venous circulation and is used for hypertensive emergency management. It has rapid onset and offset of action. The most important side effect is ______
cyanide accumulation and toxicity
| - metabolic acidosis and altered mental status.
52
The initial goal in hypertensive emergencies is to rapidly lower DIASTOLIC pressure to _____ mm Hg over 2-6 hours, with the total drop in blood pressure being no more than ___% of the initial value.
100
25%
53
Extension of dissection to the aortic arch and/or carotid arteries can cause what type of symptoms?
signs suggestive of a stroke (aphasia with associated motor or sensory abnormalities)
54
Adolescent pregnancies are associated with an increased risk of _______
```
gastroschisis,
omphalocele,
preterm birth,
low birth weight, and
perinatal mortality.
```
d/t inadequate nutrition and physiologic immaturity
55
cerebrospinal fluid (CSF) examination shows the following:
Lymphocytic pleocytosis
Elevated protein (generally 100-500 mg/dL)
Low glucose (<10 mg/dL)
Elevated adenosine deaminase
Tuberculous meningitis
56
What the Serum uric acid level during an acute gouty attack?
Nl or even low
57
Abnormal screening tests for diagnosing diabetes:
- hemoglobin A1C ____ ,
- fasting (>8 hours) blood
sugar ___
- glucose ___ after oral glucose tolerance test,
- random glucose ____
in SYMPTOMATIC patients
>6.5%
>126 mg/dL,
>200 mg/dL
Asymptomatic patients with an abnormal screening test for diabetes require a repeat measurement with the same test to confirm the diagnosis
58
Pain and stiffness >1 mo in shoulder and hip girdles
- Elevated ESR
- Morning stiffness >1 h
What disease?
Tx?
Polymyalgia rheumatica
Low dose prednisone
59
acute otitis media (AOM)
| - common bugs?
#2 nontypeable Haemophilus influenzae,
#3 Moraxella catarrhalis.
#1 Streptococcus pneumoniae,
*NOT staph
60
Depression affects up to 50% of patients with Parkinson disease (PD).
Which antidepressant med is good for pts with parkinson disease?
Same as any other pt
- SSRIs (sertraline)
- depressive symptoms may be mistakenly attributed to the progression of PD
61
__________ should be suspected in patients with fatigue, weight loss, myalgias, increased pigmentation, and decreased axillary and pubic hair.
Characteristic laboratory findings. - Hyponatremia, hyperkalemia, and hyperchloremic metabolic acidosis
Chronic adrenal insufficiency
62
Most common cause of Chronic adrenal insufficiency
addisons disease (primary adrenal insufficiency)
63
When evaluating persistent nonresolving PNA or endobronchial obstructive lesions, what is the best diagnostic test?
Next best step in management?
The best diagnostic test : flexible bronchoscopy.
Best step in management: CT scan
64
Kawasaki disease (KD) what do you do when < 3 diagnostic criteria are met in a child with >5 days of fever?
C-reactive protein or erythrocyte sedimentation rate (inflammatory markers that are elevated in KD) should be ordered,
+ daily follow-up scheduled to assess for new symptoms.
*FYI you need >4 of 5 sx for diagnosis
65
When do you perform echocardiograms in pts w/ kawasaki disease?
echocardiogram performed at baseline
+
2 and 6 weeks after completion of treatment.
* if pt has nl baseline, future risks are not increased, and no restrictions necessary
66
Orthostatic proteinuria is the most common cause of proteinuria in adolescents.
- How do you diagnose?
- How do you treat?
24 h urine collection
no intervention - benign
67
If a pt has a pneumothorax, when do you place a chest tube vs perform needle decompression?
If tension pneumo with imminent cardiac arrest: needle decompression
non-tension pneumo: chest tube
68
Which MEN syndrome?
Pituitary
parathyroids
pancreas
"Diamond"
MEN 1
| 3 P's
69
Which MEN syndrome?
- Parathyroids
- Pheochromocytoma
- Medullary thyroid Ca
"Square"
MEN 2A
mutation in the RET gene
- Marfanoid body habitus
70
Which MEN syndrome?
- Neuromas (oral/GI ganglioneuromatosis)
- Pheo
- Medullary thyroid Ca
"Triangle"
MEN 2B
Mutation in RET gene
- Marfanoid body habitus
71
Antithyroid peroxidase antibodies + Anti thyro-globulin
What disease?
What cancer?
Hashimotos thyroiditis
| - thyroid non-hodgkin lymphoma
72
Kidney donation sequelae?
low
- but increased risk of gestational complications -
- fetal loss, preeclampsia, gestational diabetes, and gestational hypertension.
- generally recommended that women complete their planned childbearing prior to kidney donation.
73
_____ are the leading cause of mortality in patients with SLE.
Cardiovascular events
| - premature coronary atherosclerosis and coronary artery disease
74
SLE patients are at increased risk for which type of cancer?
non-Hodgkin lymphoma, especially diffuse large B-cell lymphoma (DLBCL).
75
Patients with nongonococcal urethritis frequently have continued symptoms after azithromycin therapy due to reinfection or infection with an organism (eg, Mycoplasma genitalium) not susceptible to azithromycin.
- What should you do next?
repeat urethral Gram stain and nucleic acid amplification testing of the urine for common urethritis organisms.
76
Renal stones____ mm usually pass spontaneously.
Stones ___ mm, uncontrolled pain, presence of acute renal failure, and urosepsis are indications for urgent urologic referral
<5 mm
>10 mm
*if in btwn, give alpha blocker (tamsulosin) for 4 weeks and discharge
77
patient presents with knee pain, (pain out of proportion to the injury), swelling, decreased range of motion, skin changes, and vasomotor changes after a recent injury consistent with _______
complex regional pain syndrome (CRPS)
- pathogenesis is likely due to an injury causing increased sensitivity to sympathetic nerves, an abnormal response to and sensation of pain, and increased neuropeptide release causing burning pain to light touch (allodynia)
78
patient with abdominal pain, epigastric fullness, and nausea that worsen after eating has _____
- How do you treat?
dyspepsia
Management of dyspepsia is dependent on the risk of malignancy.
- age ≥60 are considered high risk and should undergo upper gastrointestinal endoscopy with biopsy.
- Those w/o alarm sx should be tested for H. Pylori. If negative treat empirically with PPI
79
Mentzer index (MCV/RBC) value of _____ is suggestive of iron deficiency and can help differentiate it from thalassemia;
>13
80
Acute hemolytic anemia is typically characterized by a (normal/low/high) MCV.
normal
81
TRUE/FALSE Papillary necrosis occurs with heavy long-term use of analgesics such as aspirin, phenacetin, acetaminophen, or other nonsteroidal anti-inflammatory drugs.
true
Analgesic nephropathy
- Ischemic damage to the renal papilla may occur due to vasoconstriction of the vasa recta. -> florid proteinuria
82
True/False
| Low folate is associated with poor cognitive function and dementia in the elderly.
true
*think alcohol use disorder
83
Apolipoprotein E polymporphisms are associated with ________
Alzheimer dementia
84
Lewy bodies are associated w/
Parkinsons disease
85
The association between DM and malignancy is well documented. Which ones?
```
adenocarcinoma of the cervix,
ovaries,
lung,
pancreas,
bladder, and
stomach.
```
86
Patients with Sydenham chorea should be started on _____ as soon as possible to eliminate carriage of group A streptococcus.
Penicillin should be continued until adulthood with the goal of preventing recurrent rheumatic fever.
87
This patient with a 30-pack-year smoking history has erythrocytosis (H/H elevated) and hematuria, raising suspicion for_______
renal cell carcinoma (RCC).
Treatment with nephrectomy is usually curative.
88
Polycystic kidney disease
- diagnosis?
- tx?
testing for PKD gene mutations
treatment with ACE inhibitors often reduces the risk of chronic renal insufficiency.
89
Patients with negative stress testing results have a ___% risk of cardiovascular events within the NEXT year.
<1%
90
Bacterial conjunctivitis can progress to bacterial _____, which most commonly occurs in patients who wear contact lenses improperly (eg, overnight use) or have decreased immunity (eg, corticosteroid use).
keratitis: inflammation of the cornea, the clear tissue covering the pupil
- can cause blindness if untreated, includes urgent referral to an ophthalmologist.
91
_____ is a bacterial infection of the sebaceous glands in the eyelid. Patients have tenderness, redness, and swelling at the eyelid margins.
Hordeolum (stye)
92
A ___-year interval for colonoscopy is appropriate for patients with 1 or 2 small tubular adenomas detected on colonoscopy or those with a first-degree relative who developed colon cancer at age <60.
5
if low risk. or relative >60 y.o then screen q10y
93
True/False
Patients with obsessive-compulsive disorder experience obsessions, compulsions, or both. Obsessions can include intrusive thoughts, violent images, and unwanted urges.
True
94
_____ is useful for the acute termination of certain paroxysmal supraventricular tachycardias (eg, AV nodal reentrant tachycardia).
Adenosine
95
Chronic kidney disease is associated with phosphate (retention/excretion),(increased/reduced) free serum calcium levels, and (increased/decreased) 1,25-dihydroxyvitamin D levels.
phosphate retention
-can cause PTH increase and autonomous PTH secretion (need parathyroidectomy)
reduced free calcium
decreased 1,25-vit D
96
Urgent warfarin reversal to prevent hemorrhage
Prothrombin complex concentrate, which contains vitamin K-dependent clotting factors and normalizes INR <10 minutes after administration.
*Intravenous vitamin K, which results in sustained warfarin reversal but takes 12-24 hours for full effect.
97
All women planning pregnancy should take ___ mg of folic acid daily for >1 month prior to conception to decrease the risk of neural tube defects; women at high risk for these defects should take ___ mg of folic acid daily.
0.4 mg
4 mg
98
________ typically presents in postmenopausal patients with a history of previous tamoxifen use or pelvic radiation.
Presenting symptoms can include new-onset pelvic pressure or pain, a uterine mass, ascites, and symptoms of metastasis (eg, pleural effusion).
Uterine sarcoma
99
Screening for gestational diabetes mellitus is performed at ____ weeks gestation with the 1-hour 50-g glucose challenge test.
24-28 weeks
100
Patients with chronic hepatitis C infection should be vaccinated against _____ and _____ if they do not have preexisting immunity.
HAV and HBV
pts can have rapid hepatic decompensation and liver failure if they develop acute hepatitis A virus (HAV) or hepatitis B virus (HBV) infection.
101
Patients with a Centor score <3 have a low probability of a acute pharyngitis (GAS infection); they do not require testing or antimicrobial treatment and can be managed symptomatically.
What are sx of acute pharyngitis?
Tonsillar exudate
Tender anterior cervical adenopathy
Fever
Absence of cough
102
________ in sickle cell disease is defined by the presence of a new pulmonary infiltrate on chest x-ray and fever, hypoxemia, chest pain, tachypnea, or increased work of breathing.
- How do you tx?
Acute chest syndrome
| - tx w/ ceftriaxone and macrolide (eg, azithromycin), pain control, and intravenous fluids.
103
This patient, with back pain, high PTH, low phosphorus level, nl calcium, high alkaline phosphatase, and history of bariatric surgery, has likely _____ deficiency
vitamin D deficiency
- Serum 25-hydroxyvitamin D level is a very sensitive indicator for vitamin D stores and should be measured in patients suspected of vitamin D deficiency. A level <20 ng/mL is diagnostic.
104
Patients with ______ often have labile diabetic control and frequent hypoglycemia as it is difficult to time their insulin dose to correspond with the delayed intestinal absorption of glucose.
- how to evaluate?
gastroparesis
- first r/o mechanical obstruction
- If diabetic gastroparesis suspected: nuclear gastric emptying study to confirm the diagnosis.
105
__________ and __________ are used to exclude mechanical obstruction
Upper gastrointestinal endoscopy
contrast imaging studies such as barium swallow
106
Patients with acute ischemic stroke who are treated with tissue plasminogen activator should not receive antiplatelet therapy, anticoagulation, or invasive testing during the first ____(time)___ after treatment.
24 hours
107
What is recommended after a pt receives TPA?
Strict control with intravenous medications such as labetalol, nitroprusside, or nicardipine is recommended to keep blood pressure <185/105 mm Hg ( but >140/90 mm Hg) to avoid the risk of hemorrhagic transformation.
108
Antiplatelet (eg, aspirin) therapy should not be used in the first ___ hours after tPA but could be started after ____hours if the patient is stable.
24
24-48
109
With CYP inhibitors, warfarin effect (increases/decreases)
increases (warfarin metabolism slows)
(INR increases)
*so you should reduce warfarin dose 25-50% to compensate
110
With CYP inducers, warfarin effect (increases/decreases)
decreases,
(warfarin metabolism increases)
*so you should increase warfarin dose to compensaet
111
__________ presents with hyperthyroidism and a nontender goiter in the first year after pregnancy
Postpartum thyroiditis (PT)
associated with thyroid peroxidase antibodies
112
Lithium has a very narrow therapeutic index. Many antihypertensive medications can interact with lithium due to their effects on renal function and electrolyte levels. How? Which ones are considered safe?
Thiazides, ACE-i, and ARBs can increase serum lithium levels.
Calcium channel blockers are generally considered safe.
113
Potassium-sparing diuretics (eg, spironolactone) can (increase/decrease) serum lithium levels
decrease - making them subtherapeutic
114
A patient in labor w/ a h.o C-section, has acutely worsening abdominal pain, vaginal bleeding, loss of fetal station, and an abnormal fetal heart rate tracing with late decelerations. This presentation is concerning for _____
uterine rupture, full-thickness disruption of the uterine wall.
115
Acute respiratory failure due to OSA results from _________ (evidenced by bibasilar atelectasis on chest x-ray), and typically leads to hypercapnic, hypoxic respiratory failure (acute on chronic hypercapnic, hypoxic respiratory failure in this patient) with respiratory acidosis.
hypoventilation
*Patients with obstructive sleep apnea are at increased risk of perioperative respiratory failure from procedures involving sedation, neuromuscular blocker, opioids, or anesthesia. When respiratory failure occurs, it results from hypoventilation and typically presents with hypercapnia and hypoxia.
116
if the gastrointestinal tract is able to function, then _____ feedings are preferred to _____ feeds in pts w/ functioning gastrointestinal system.
The standard composition of ___ kcal/kg/day and __ g/kg/day of protein is satisfactory for most patients with adequate baseline nutrition.
enteral (passing thru intestines/GI) > parenteral (anywhere but the mouth and alimentary canal)
30 kcal/kg/day
1 g/kg/day
117
________ and _______ levels can be used to monitor for active renal involvement in patients with systemic lupus erythematosus.
Antinuclear antibody titers do not correlate with renal disease activity!!
Anti-double stranded DNA
Complement levels
118
_______ presents with a petechial rash, neurologic abnormalities, thrombocytopenia, and microangiopathic hemolytic anemia.
Can occur during pregnancy or in the postpartum period.
Thrombotic thrombocytopenic purpura (TTP)
119
__________ typically presents with an altered mental status, oculomotor dysfunction (eg, nystagmus) and gait ataxia
Wernicke encephalopathy (eg, thiamine deficiency)
120
older patient who recently had a myocardial infarction and now has severe abdominal pain out of proportion to his benign examination findings, along with an anion gap metabolic acidosis, should be considered to have __________until proven otherwise.
- Test?
acute mesenteric ischemia
- CTA
- Oral contrast should be avoided with acute mesenteric ischemia as it can obscure the vasculature.
- most common cause is superior mesenteric artery occlusion due to embolic disease
121
True/False
In >55% of patients, strokes can cause abnormalities in the swallowing mechanism, leading to possible oropharyngeal dysphagia, aspiration, and aspiration pneumonia.
True
| - This is associated with an increased risk of death. Assessment of swallowing function
122
How do you treat stroke pts who present >4h after sx?
Aspirin and permissive HTN
- <185/105 mm Hg ( but >140/90 mm Hg)
*Do not give fibrinolytic therapy
123
The risk of DVT is highest ____days following a stroke and is particularly high in patients with hemiparesis (up to 75% on the hemiparetic side). Subsequent pulmonary embolism is the most frequent cause of early death in acute stroke patients.
2-7 days
| - give subcutaneous low-dose heparin or low-molecular-weight heparin for deep-vein thrombosis (DVT) prophylaxis
124
True/False
Full-dose intravenous heparin is used for the treatment of DVT, not its prophylaxis.
True/False
Full-dose anticoagulation is generally used to treat acute stroke
True
False:
Full-dose anticoagulation is not generally used to treat acute stroke due to the risk of hemorrhagic transformation of the infarct.
125
______ lab is used to screen for medullary thyroid cancer
Calcitonin
126
__________ syncope is usually preceded by an autonomic prodrome of nausea, pallor, diaphoresis, or generalized warmth. These symptoms often temporarily persist following the episode.
Neurocardiogenic (vasovagal) syncope
127
Palpitations prior to an episode of syncope or ABSENCE of preceding autonomic prodromal symptoms are suggestive of _______ syncope
cardiogenic - due to cardiac arrhythmia (eg, ventricular tachycardia).
128
PCP intoxication leading to severe agitation and violent behavior should be treated immediately with __________.
___________ is more appropriate for patients with milder symptoms of PCP intoxication.
benzodiazepines to provide sedation
A low-stimulation environment (with or without benzodiazepines)
129
cat-scratch disease (CSD) caused by Bartonella henselae tx?
Azithromycin treatment can reduce the length and severity of symptoms.
Doxycycline (plus rifampin) treats neurologic manifestations of CSD in patients age >8.
- However, prolonged doxycycline is avoided in young children due to the risk of dental staining, and this patient has no neurologic findings.
130
The constellation of unilateral headache and partial left-sided Horner (ie, ptosis, miosis, anhidrosis) syndrome indicates left carotid artery dissection until proven otherwise.
- what do you do?
Diagnosis is typically by CT angiography or MR angiography;
if the results are negative but carotid dissection is still suspected, catheter angiography (gold standard) may be performed
131
_________ lobe lesions present with constructional and dressing apraxia.
Nondominant parietal
132
Damage to the ________ lobe, presents as Gerstmann syndrome.
The patients have difficulty in performing simple arithmetic tasks (acalculia), inability to name individual fingers (finger agnosia), impaired writing (agraphia) and right/left confusion (difficulty in identifying or distinguishing the right or left side of the body).
dominant parietal
| - especially the inferior parietal lobe
133
Wernicke's aphasia is usually seen in patients with _______ lobe lesions. It is characterized by the impairment in comprehension of spoken or written language. Patients have difficulty in expressing their thoughts in a meaningful manner.
dominant temporal
134
________ presents as irregularly shaped, hyperpigmented macules on the face.
It occurs more commonly during pregnancy.
Management?
Melasma
| - minimizing sun exposure and using a broad-spectrum sunscreen that blocks both UVA and UVB radiation.
135
The pathophysiology of toxic shock syndrome involves_______
widespread activation of T cells by EXOTOXIN acting as superantigens, leading to the massive release of cytokines.
136
The pathophysiology of septic shock involves_______
massive bacterial lysis and circulating endotoxin
137
________ is often characterized by low T3 levels with normal TSH and T4 in patients with acute illness. It is primarily due to decreased peripheral conversion of T4 to T3. Treatment is not recommended
Euthyroid sick syndrome
| "low T3 syndrome"
138
NF1 vs NF2
- which one causes unilateral vs b/l deafness?
- which one is most assoc w/ cafe au lait macules?
NF1: unilateral
- CALMs classic
NF2: b/l (acoustic neuromas)
139
Scoliosis
- Cobb angle < 10 degrees
- Cobb angle 10-40 degrees
- Cobb angle ≥40 degrees
- Cobb angle < 10 degrees: nl variant
- Cobb angle 10-40 degrees: mild scoliosis -
If skeletal maturity is incomplete ->back brace.
If skeletal maturity is complete -> nothing, no follow up
- Cobb angle ≥40 degrees: Severe scoliosis - surgical eval
140
Can C-section prevent the vertical transmission of HPV (condyloma acuminata?)
no
| - proceed with expectant management and vag delivery
141
How to prevent malaria?
```
Antimalarial prophylaxis (abx), which generally needs to be started in advance of a trip and continued for some time after a traveler's return
- There are no antimalarial vaccines currently available.
```
142
Brain death diagnosis requires a CNS catastrophe of known etiology with an absence of confounding factors.
Ptsmeeting clinical criteria should undergo neurologic examination to document absent cortical and brainstem function (eg, coma, absent motor response to pain, absent pupillary light reflex, absent corneal and oculocephalic reflexes, absent gag reflex).
- Then what do you do?
Apnea testing is used to confirm the diagnosis of brain death in patients meeting these criteria.
143
________ is the most frequent complication of transurethral resection of the prostate, and all patients should be made aware of this.
Retrograde ejaculation
144
________ is the most common cause of secondary dilated cardiomyopathy, and evaluation with ________ or coronary angiography should be performed in all patients presenting with unexplained heart failure due to left ventricular systolic dysfunction.
Coronary artery disease
stress testing
145
Hypoglycemia is a risk with insulin and several oral medications for diabetes, especially ______ and _____
sulfonylureas (eg, glyburide, glipizide, glimepiride)
and
meglitinides (eg, nateglinide, repaglinide).
146
What is plasma aldosterone to plasma renin activity ratio used to screen for?
- Ratio # to look for?
```
primary hyperaldosteronism (Conn's syndrome)
- hypokalemia and hypertension
```
ratio of >30 is suggestive of excessive aldosterone secretion from the adrenal gland.
147
________ wound infections are often associated with rapidly progressive cellulitis with hemorrhagic bullous lesions, and septic shock.
- Infections are acquired primarily through the consumption of raw oysters or through wound contamination during recreational activities or raw seafood handling.
Vibro vulnificus
148
________ is found in salt and fresh water and can cause wound infections.
- lesions are usually papular and ulcerative (not necrotizing and bullous) and develop over several days (not hours).
Mycobacterium marinum
149
The presence of HbA and HbS in a 60:40 ratio, respectively, is consistent with _______, which is generally asymptomatic and not a cause of anemia and microcytosis.
sickle cell trait
150
Low 8:00 AM cortisol and glucose suggest __________.
Then what?
adrenal insufficiency
Measurement of baseline adrenocorticotropic hormone (ACTH) levels and a short ACTH (cosyntropin, synthetic ACTH) stimulation test would be the most practical methods to assess adrenal reserve.
151
Ambulatory 24-hour Holter monitoring is often helpful in the diagnosis of suspected _______, but it has minimal diagnostic use for CAD.
paroxysmal cardiac arrhythmia
152
Either of 2 serious complications is an absolute contraindication to future DTaP immunization: _____ immediately after the vaccination or _______within 7 days.
anaphylaxis
encephalopathy
*note: Immunosuppression of any kind is not a contraindication to DTaP immunization.
153
HPV vaccines target types that cause either genital warts (eg, types __ and __ ) or cancer (eg, types __ and __).
warts: 6 and 11
cancer: 16 and 18
154
The recommended time for the first dose is age 11-12, but the HPV vaccine series can be started at age __- __
9-26
155
_____________ can be obtained in case-control studies and are a useful measure of association.
Odds ratios (but not relative risks or risk ratios)
156
(macrocytic anemia with a normal serum folate level and severely depressed serum cobalamin level suggest the presence of ______ anemia.
B12-deficiency
157
_______ testing is the recommended initial test for the detection of pernicious anemia.
Anti-IF antibody test
*note: antiparietal antibodies also assoc w/ pernicious anemia. but less specific
158
Schilling test is a classic diagnostic test of _________ that uses radio-labeled cobalamin.
pernicious anemia
| - It is more cumbersome than antibody testing, and can be used as the second-line test if the anti-IF test is negative.
159
three main components of autoimmune metaplastic atrophic gastritis (AMAG) (which is associated with pernicious anemia) are:
1. glandular atrophy of gastric body and fundus.
2. intestinal metaplasia
3. intestinal inflammation.
Typically, little changes are observed in the gastric antrum.
160
acute asthma exacerbation, current guidelines recommend initial home management with short-acting bronchodilators (eg, albuterol) followed by the addition of ________ if symptoms persist
systemic PO corticosteroids (eg, prednisone)
*Inhaled corticosteroids are used as a controller medication for the chronic management of persistent asthma. However, they do not play a role in management of an acute asthma exacerbation
161
Confirmation of H. pylori eradication is recommended for patients with ulcers or ongoing dyspepsia. __________ can be used after 4 weeks to confirm H. pylori eradication
Either urea breath or fecal antigen testing
162
Pneumococcal vaccines for age > 65
13-valent pneumococcal conjugate vaccine (PCV13) at age 65, followed by the 23-valent pneumococcal polysaccharide vaccine (PPSV23) in 6-12 months
- Revaccination in 3 years
163
_________ is a scalp swelling above the periosteum that crosses suture lines. A benign condition that presents at birth
Caput
| succedaneum
164
___________is a subperiosteal bleed that takes several weeks to resolve and, in contrast to subgaleal hemorrhage and caput succedaneum, does not cross suture lines
cephalohematoma
165
All patients with asymptomatic LVSD (ejection fraction <40%) should be treated with _______ as treatment has been shown to delay the onset of symptomatic heart failure and improve long-term cardiac morbidity and mortality.
ACE inhibitor (or angiotensin II receptor blocker)
Once a suitable ACE inhibitor dose has been achieved, beta blocker therapy should be added.
166
Absent or reversed umbilical artery end-diastolic flow (as seen in this patient) suggests ___________ and impending ______, particularly with concomitant oligohydramnios, and is an indication for delivery
placental insufficiency
fetal hypoxia
167
First line onychomycosis tx?
PO Terbinafine, itraconazole
*note: griseofulvin and ketoconazole are rarely used for onychomycosis - long tx regimens w/ freq monitoring (but still used for tinea capitus)
168
________ fracture is common following a fall onto an outstretched hand.
- Patients with this injury frequently have additional styloid fracture, scaphoid fracture, and acute carpal tunnel syndrome.
Distal radius (Colles')
169
Statin therapy is recommended for all patients age 40-75 with diabetes (type 1 or type 2) who have a baseline LDL level __ mg/dL.
>70
170
Screening for diabetic retinopathy is indicated beginning _____ after the original diagnosis in patients with type 1 diabetes and _____ in those with type 2.
Type 1: 3-5 years
Type 2: at the time of diagnosis
171
Diabetic pts w/ evidence of nephropathy or HTN should be treated w?
ACE-i
172
For pregnant pts w/ mechanical valves. Which anticoagulant is used in:
1st trimester?
2nd?
3rd?
1st trimester (organogenesis): LMWH
2nd and third trimester: warfarin
Last few weeks of pregnancy: unfractionated heparin (quickly reversed w/ protamine)
*note: Warfarin prophylaxis can be resumed during breastfeeding as it does not accumulate in breast milk.
173
mid-systolic murmur at the left upper sternal border (resulting from increased flow across the pulmonic valve) with right atrial and ventricular dilation – is most suggestive of __________.
- Many patients remain asymptomatic until adulthood.
atrial septal defect (ASD) with a left-to-right shunt.
- second most common congenital heart defect in adults (bicuspid aortic valve is the most common)
174
Patients with ________ typically have a harsh holosystolic murmur with maximal intensity over the left 3rd and 4th intercostal spaces, often accompanied by a palpable thrill
ventricular septal defect (VSD)
175
______is a common cause of postoperative hypoxemia that can occur 2-5 days following surgery; is uncommon immediately following surgery, and usually fails to correct w/ supplemental oxygen d/t intrapulmonary shunting
Atelectasis
176
Which diuretics should be avoided in pts w/ gout?
HCTz and furosemide
| - decrease fractional excretion of urate
177
______ is required for diagnosing a prolapsed internal hemorrhoid, which can present as inflamed veins in the left lateral and right anterior/posterior walls of the anal canal
Anoscopy
178
_________ is characterized by pituitary enlargement, hyperpigmentation, and visual field defect following bilateral adrenalectomy. Usually, these tumors are rapidly growing and can be treated with surgery and/or local radiation.
Nelson's syndrome
179
Acute gouty monoarticular arthritis in renal failure and post-transplant patients is best treated by ______
increasing the dose of systemic steroids or by injection of intraarticular glucocorticoids.
* use of allopurinol, probenecid, NSAIDs and colchicine is not recommended in such patients.
180
What do you do if pt develops
| VTE while on menopausal hormone therapy (MHT)?
Stop hormone therapy as the benefit of continued treatment does not outweigh the risk of recurrent, potentially life-threatening VTE.
- most common alternate treatments are SSRIs or SNRIs
181
Vulvodynia is a chronic (>3 months), raw, burning vulvar pain that occurs in the absence of a specific disorder. First-line management includes _________ and _____
pelvic floor physiotherapy and cognitive behavioral therapy.
182
Topical clobetasol, a high-potency corticosteroid, is indicated for treatment of __________ that typically present with intense vulvar pruritus in perimenopausal patients.
inflammatory vulvar disorders
| eg, lichen sclerosus, lichen planus, psoriasis
183
Aphasia is typically seen in _________ lobe lesions.
dominant temporal
184
Peripartum Pts w/ ________ can have new onset of hypertension, pulmonary edema, and hyperreflexia (ie, end-organ damage).
- typically occurs during pregnancy, but it can also occur up to 12 weeks postpartum and can be complicated by ________
preeclampsia
pulmonary edema
185
_________ is the most common side effect of the combined oral contraceptive pill and occurs due to a thin atrophic unstable endometrium that sheds erratically.
Unscheduled bleeding
- other common side effects: breast tenderness, nausea, headaches, and moodiness
186
Pt w/ history of abdominal surgery, swinging fever, and leukocytosis 14-21 post-op.
- Cough and shoulder-tip pain may be the presenting symptoms.
suspected subphrenic or other abdominal abscess
187
The anthracycline class of drugs causes a dose-dependent decline in the ejection fraction, leading to _________
dilated cardiomyopathy.
*radiation causes diffuse fibrosis, restrictrive cardiomyopathy
188
Cervical insufficiency, a structural cervical weakness associated with painless second-trimester pregnancy loss, is managed with placement of a cerclage.
- how much can they exercise?
exercise is contraindicated
Patients with a cerclage and history of cervical insufficiency should avoid exercise during pregnancy to minimize the risk of preterm delivery
189
Spontaneous descent of undescended testes is rare after age ____, and an orchiopexy is performed during infancy to optimize fertility and testicular growth.
6 months
| - refer for surgery
190
Children with latent tuberculosis infxn require Daily isoniazid for 9 months.
- If isoniazid resistance is suspected, the best alternate therapy is _________
daily rifampin for 4-6 months.
191
________is a nonmalignant lesion that arises in the terminal ducts and lobules of the breast.
- What do you do?
Lobular carcinoma in situ (LCIS)
- While the lesion itself has no malignant potential, it signifies an increased risk of developing invasive lobular or ductal carcinoma in either breast (roughly 7-18 times the risk)
- biopsy, if + then excisional bx
192
________represents the simplest and least toxic acute treatment of a prolonged bleeding time. It acts by increasing the release of factor VIII:von Willebrand factor multimers from endothelium.
Desmopressin
193
Organophosphate poisoning typically occurs after exposure to or ingestion of agricultural pesticides; ___________ inhibition causes a cholinergic toxidrome.
- tx?
acetylcholinesterase
reversal agents: Atropine and pralidoxime
194
Statins alone may reduce serum triglyceride levels about __%.
In addition to lifestyle modifications, patients with more significant triglyceride elevations, especially those with >1000 mg/dL, should be given _____ therapy (or fish oil or niacin if fibrates are not tolerated) to reduce the risk of pancreatitis
10%-30%
fibrate
195
True/False
Statin therapy is recommended for patients with known atherosclerotic cardiovascular disease, only if the low-density lipoprotein cholesterol level is >190
False
Statin is recommended REGARDLESS of baseline low-density lipoprotein cholesterol levels.
196
Corticosteroids should be given to pts w/ bells palsy (unilateral upper and lower facial weakness) w/in how many days?
3 days to improve chances of complete recovery
197
After a bone age radiograph is used to assess remaining growth potential, part of the Initial evaluation includes FSH, LH, and testosterone levels to differentiate between ___ and ___
primary (elevated FSH/LH) hypogonadism
and
secondary (low to normal FSH/LH) hypogonadism.
198
Patients with diaphragmatic paralysis typically present with shortness of breath that is worse in the ____ position, and as a result, it is easy to see how this symptom can erroneously lead to a cardiac workup.
supine
*ie: pts w/ ALS, the most common cause of b/l diaphragmatic paralysis
199
Procedures that warrant antibiotic prophylaxis for IE in patients with high-risk cardiac conditions in the absence of active infection include:
Dental procedures that involve manipulation of gingival tissue or the periapical region of teeth (eg, routine dental cleaning) or perforation of the oral mucosa
Respiratory tract procedures that involve incision or biopsy of the respiratory mucosa (eg, tonsillectomy, bronchoscopy with biopsy)
Surgical placement of prosthetic cardiac material
200
Bacterial enteritis is characterized by fever, abdominal pain, and bloody diarrhea. _______ is the first-line treatment for mild dehydration. _____ are indicated only for patients with invasive disease.
An oral electrolyte solution
Antibiotics
201
Spinal cord compression develops in up to ___% of patients with Pancoast tumor (lung ca) and may result in paraplegia.
- Early recognition and corticosteroid therapy, surgery, and radiation is imperative to preserve neurologic function and patient autonomy.
25%
202
Asymptomatic pts w/ sarcoidosis often require no tx; those with symptoms or pulmonary function impairment usually receive 12-24 months of oral glucocorticoids.
- What the prognosis?
Most cases (~75%) resolve over time and do not recur.
203
_____ should be considered in patients with Molluscum contagiosum (MC), especially for lesions that are widespread or involve the face.
HIV testing
MC: spread skin to skin contact
204
genu varum is considered physiologic from age __ to ___
birth to age 2 years
- reassurance and observation
*get b/l leg xray if bowing is progressive, unilateral, persistent after age 3 years, or associated with short stature (eg, possible metabolic disease)
205
Improving myocardial contractility with can be achieved with ______. It is recommended only in patients with severe LV dysfunction and low cardiac output causing poor peripheral perfusion or end-organ dysfunction.
intravenous inotropic agents (eg, dobutamine, milrinone)
206
Good prognostic factors of schizophrenia
```
late age
acute onset (no prodrome)
positive psychotic symptoms (eg, delusions, hallucinations) typically respond well to antipsychotic medication
```
207
Pregnant Pts w/ Sickle cell disease can have _____ when Hepatic sinusoid vaso-occlusion occurs as sickled RBCs sequester within hepatic sinuses, causing tissue ischemia and infarction (eg, right upper quadrant pain, elevated transaminases) and systemic inflammation (eg, fever)
acute sickle hepatic crisis
| - can present during pregnancy with fever, nausea, vomiting, right upper quadrant pain, and elevated transaminases
208
HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome typically presents in the _____ trimester with hypertension, proteinuria, and a platelet count <100,000 cells/mm3.
third
209
G6PD deficiency also can result in severe ______ hyperbilirubinemia and anemia on day of life 2-3
unconjugated (indirect)
210
Biliary atresia results from progressive destruction of the extrahepatic biliary tree.
- As bilirubin is conjugated in the liver and proximal to the site of obstruction, the hyperbilirubinemia in biliary atresia is _______
conjugated (direct)
211
______ is a contagious, superficial skin infection that presents with painful erythematous pustules and a classic overlying honey-colored crust.
Impetigo
212
______ is a superficial skin infection but presents with well-demarcated, bright red erythema, classically on the cheeks.
Erysipelas
213
__________ presents in phenotypical females with primary amenorrhea (absent uterus) and absent pubic/axillary hair but normal breast development.
Diagnostic features include an absent uterus but intact testes, a (46, XY) karyotype, and serum testosterone levels in the normal adult male range.
Androgen insensitivity syndrome
214
______
- uterus absent
- ovaries present
- secondary sexual characteristics develop normally (pubic/axillary hair)
Müllerian agenesis
215
Does polymyalgia rheumatica cause stiffness or weakness?
| Is it more common in those > or < than 50?
Stiffness
More common in pts age >50
*this is opposed to polymyositis - more commonly painless muscle weakness and peak at age 40-50
216
patients age <30 w/ palpable breast masses
| - what do you do?
ultrasound
if suspicious -> core biopsy
217
_________ are the first-line therapy for mild-to-moderate, localized plaque psoriasis on the extensor areas and face?
Extensor areas: High-potency topical corticosteroids (fluocinonide augmented betamethasone 0.05%)
On face and intertriginous areas: Low-potency steroids (eg, hydrocortisone 1%)
218
LVEF >50% is considered normal in most patients; however, in patients with severe, chronic primary MR, LVEF
60%
| - mitral valve repair or replacement is typically indicated.
219
Chronic MR is classified as ____ in the presence of associated symptoms (eg, dyspnea on exertion, HF) or specific ECHO findings (eg, LA and LV enlargement, regurgitant jet prominence).
severe
220
Diagnosis of duchenne muscular dystrophy?
serum creatine kinase (CK) level
- released with muscle inflammation or damage.
genetic testing can confirm the diagnosis.
Muscle biopsy is not required for diagnosis but will show fibrosis, fat, and muscle degeneration
221
(Hyper/Hypocalcemia) can occur during or immediately after surgery, especially in patients undergoing major surgery and requiring extensive transfusions. ______ may be the initial manifestation.
HYPOcalcemia
- Hyperactive deep tendon reflexes
Hypermagnesemia, on the other hand, results in loss of the deep tendon reflexes.
222
________is a potential complication of arterial access for cardiac catheterization; it occurs when arterial bleeding remains confined within the periarterial connective tissue, resulting in a contained hematoma that communicates with the arterial lumen.
- How do pts present?
Pseudoaneurysm
Patients typically have a tender, pulsatile mass with a systolic bruit at the puncture site, and the diagnosis is confirmed by ultrasonography.
223
_____ are the agents of choice in the treatment of scleroderma renal crisis.
Most patients respond favorably if these drugs are used promptly after the diagnosis, and the goal should be to reduce blood pressure to baseline over 72 hours.
ACE inhibitors
- since these reverse the angiotensin-induced vasoconstriction.
(choice is captopril - short time to onset)
While ACE inhibitors are generally avoided in most patients with acute renal failure, scleroderma renal crisis is an exception to this general rule as long as renal function is closely monitored.
224
*Rh(D)-negative women are at risk for alloimmunization due to fetomaternal hemorrhage from abruptio placentae after abdominal trauma.
A _______ test determines the presence and quantity of fetomaternal hemorrhage so that the amount of Rho(D) immune globulin to be administered can be calculated.
Kleihauer-Betke
225
Oral candidiasis typically causes white lesions on the oral mucosa that are easily removed with scraping. Patients with oral candidiasis and no history of recent antibiotics, inhaled corticosteroids, or systemic chemotherapy should be evaluated for _________
HIV infection with a fourth-generation HIV test (p24 antigen and HIV-1/HIV-2 antibody).
226
_________, caused by end-organ resistance to parathyroid hormone (PTH), causes chronic hypocalcemia, hyperphosphatemia, and elevated PTH.
Pseudohypoparathyroidism
227
Seizures, muscle cramping, hyperreflexia, basal ganglia calcifications, and cataracts are signs of _______.
hypocalcemia
228
_____ are considered first-line treatment for hypertension in patients with HCM.
Beta blockers
- Lisinopril and other vasodilators cause a reduction in systemic vascular resistance, potentially worsening the left ventricular outflow tract gradient in patients with HCM.
229
______ is an acquired syndrome due to the formation of autoantibodies against ADAMTS13, a plasma metalloprotease responsible for cleaving ultralarge strings of vWF off the vascular endothelial wall. .
When levels of ADAMTS13 become severely deficient, uncleaved strings of vWF trap and activate platelets, resulting in diffuse microvascular thrombi.
thrombotic thrombocytopenic purpura (TTP)
230
Patients who have clinical and laboratory data that support the diagnosis of TTP require urgent treatment with plasma exchange.
- how does that work?
It removes the autoantibody against ADAMTS13 and replenishes the enzyme with ADAMTS13 from donor serum.
231
the typical frequency of stool passage in an exclusively breastfed newborn is ____ times daily, or approximately one soft, yellow-green stool per episode of breastfeeding.
After the first month, the stooling frequency in some infants decreases to ____
6-10
1 episode every 1-2 days or less, with some having only 1 or 2 bowel movements per week.
232
Genu varum ("bow legged") with outward bowing at the knee is normal at age ___
Genu valgum ("knock-knees") is a symmetric angulation of the knees toward the midline that occurs in children age __
6 months
2-5 years
233
The first step in the management of HHS is ______
aggressive fluid resuscitation (typically with isotonic saline), as these patients frequently have had a fluid loss of 8-10 liters.
234
Tourette syndrome is associated with several comorbid conditions; such as ____ and ___
attention-deficit hyperactivity disorder and obsessive-compulsive disorder are the most common.
235
Switching from fluoxetine (an SSRI) to an MAOI requires a __week washout.
5-week
236
Abrupt discontinuation of SSRIs can result in a withdrawal syndrome characterized by agitation, irritability, headache, dizziness, flu-like symptoms, and paresthesias. ______, however, is least likely to cause discontinuation symptoms due to its relatively long elimination half-life.
Fluoxetine
237
NMS vs Serotonin syndrome
mental status changes, clonus, tremors and hyperreflexia
Serotonin syndrome
- clonus
*note: can have some muscle rigidity, but it wont be lead pipe muscle rigidity
238
Herbal Supplement
Ginkgo biloba
- Uses
- Side Effects
Memory enhancement
Increased bleeding risk
239
Herbal Supplement
Saw palmetto
- Uses
- Side Effects
BPH
Mild stomach discomfort
Increased bleeding risk
240
Herbal Supplement
St John's wort
- Uses
- Side Effects
Use: Depression + insomnia
```
Drug interactions:
- Antidepressants (serotonin syndrome),
- OCs,
- anticoagulants (↓ INR), digoxin
Hypertensive crisis
```
241
Herbal Supplement
Licorice
- Uses
- Side Effects
Use: Stomach ulcers
Bronchitis/viral infections
SE: Hypertension
Hypokalemia
242
Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity disorder that occurs in patients with ____ or ____. Noninvasive colonization of the airways by Aspergillus species.
asthma or cystic fibrosis.
Pathophysiology of ABPA is exaggerated IgE and IgG-mediated immune response to the fungus in the context of preexisting asthma.
- improves w/ corticosteroids
243
How does amiodarone affect the heart?
causes cardiac bradyarrhythmias, not heart failure
244
______ is a common complication of coronary artery bypass graft surgery that can cause peripheral edema and elevated jugular venous pressure (JVP) with clear lung fields (right heart failure), hepatojugular reflex
constrictive pericarditis
245
How does Organophosphate poisoning causes cholinergic toxicity?
Whats the tx?
via acetylcholinesterase inhibition
Atropine - reverses muscarinic receptor effects
+
Pralidoxime - acetylcholinesterase reactivator
246
Valproate carries the highest teratogenicity risk of all AEDs; therefore, changing to an alternate regimen should be tried __ months prior to attempts to conceive.
- What happens if confirmation of pregnancy already took place?
6 months
No changes to the AED regimen should be made after conception, as abrupt changes may trigger seizure activity.
It is preferable to switch to the lowest possible dose of a single medication to limit teratogenicity.
247
Hidradenitis suppurativa (acne inversa) is an inflammatory disorder of the skin most commonly involving the intertriginous areas (eg, axillae, groin, medial thigh, perineal area).
- Mild cases can be managed with______.
- Moderate cases with sinus tracts and scar formation require ____
- More severe cases with diffuse involvement and extensive sinus tract formation may require _____
Mild: topical antibiotics (eg, clindamycin)
Moderate: oral antibiotics (tetracyclines preferred).
Severe: TNF-alpha inhibitors (eg, infliximab) and wide surgical excision.
248
First-line treatment for tinea capitis is a systemic antifungal _____
either oral griseofulvin or oral terbinafine.
| - An oral agent must be used in the treatment of tinea capitis to penetrate hair follicles
249
How do you diagnose Subarachnoid hemorrhage?
noncon CT
followed by
lumbar puncture for xanthochromia
250
_______ can effectively treat tension headaches refractory to initial nonsteroidal anti-inflammatory drugs.
Acetaminophen combined with aspirin and caffeine
251
Should you pace patients with PEA or asystole cardiac arrest?
No
You should use Chest compressions + Epi 1 mg q3-5 min
252
Treatment for Chronic Bacterial Prostatitis?
After confirmation w/ DRE (warm, edema, tender)
Treatment requires 6 weeks !! of a fluoroquinolone (eg, ciprofloxacin) or trimethoprim-sulfamethoxazole.
- patients may have recurrent symptoms if treated for shorter duration
253
____ is a somatostatin analogue that decreases insulin secretion and should be considered in patients with a large sulfonylurea overdose after Dextrose is given.
Octreotide
*note: dextrose is first line
254
In patients with chest pain, the probability of clinically significant (CAD) is based on chest pain characteristics, patient age, sex, ECG findings, and CAD risk factors.
_____ is preferred in patients who are able to walk and do not have significant abnormalities on resting ECG
Exercise ECG
255
Bile salt-induced diarrhea is seen with cholecystectomy, ileal resection, or short bowel syndrome.
- Bile acid flux causes colonic stimulation
- How do you treat?
bile salt-binding resins such as cholestyramine.
256
Marked increase in serum creatinine after initiation of ACE inhibitor therapy is highly suggestive of _______
renal artery stenosis (typically bilateral or unilateral stenosis of a solitary kidney or a TRANSPLANT).
- Renal artery stenosis leads to stimulation of the renin-angiotensin-aldosterone system, which results in hypertension and normal renal function
257
_______ is the most effective nonpharmacologic measure to decrease blood pressure
Weight loss
followed by the DASH diet
258
Why do pts w/ infective endocarditis present with cough and pleuritis chest pain and x-ray showing multiple nodular opacities?
septic pulmonary emboli, a complication that occurs in 75% of cases of right-sided IE
- higher risk in pts w/ low CD4 count
259
treatment for iodine-induced hyperthyroidism/thyrotoxicosis:
Mild: BB
| If persistent or severe or in older patients w/ heart conditions: thionamides (methimazole)
260
he six P's of ___: pain, pallor, paresthesia, pulselessness, poikilothermia, and paralysis.
- no doppler signals
acute limb ischemia (impending irreversible myonecrosis)
- need anticoagulants and emergency surgical revascularization
261
main cause of morbidity Marfan Syndrome is aortic root disease, manifesting as _______
aneurysmal dilation,
aortic regurgitation,
and/or dissection
262
All patients with scleroderma should be screened with _______ at diagnosis.
pulmonary function testing
- pulmonary hypertension (more commonly seen with CREST syndrome): drop in DLCO and preserved TLC
- interstitial lung disease (more commonly seen with diffuse cutaneous disease): drop in both DLCO and TLC
263
_________ are first-line treatment for prolactinomas, including large prolactinomas
Dopaminergic receptor agonists (cabergoline/bromocriptine)
Treatment with dopaminergic receptor agonists generally leads to a decrease in tumor size within a few days. Visual symptoms usually improve before the tumor's decrease in size is seen on MRI.
*Transphenoidal and transcranial surgery is rarely required for patients with prolactinomas, but are used for pts w/ nonfunctioning pituitary adenomas
264
During treatment of unconjugated (indirect) hyperbilirubinemia, phototherapy should continue until bilirubin declines to below threshold levels.
- Exchange transfusion should be considered if bilirubin is at toxic levels ______ .
- What are you worried for?
(>20-25 mg/dL).
| - worried for kernicterus or bilirubin encephalopathy.
265
Hydroxyurea reduces the frequency of vaso-occlusive episodes in patients with SCD
- How long does it take to take effect?
several months to take effect.
It is not used in the treatment of an acute vaso-occlusive episode.
266
_________ is a significant predictor of adverse cardiovascular outcomes, especially in women. It is considered to be a coronary heart disease risk equivalent.
Diabetes mellitus
- Strict glycemic control significantly lowers microvascular complications (eg, retinopathy, nephropathy, neuropathy) but does not consistently reduce macrovascular complications (eg, CHD, stroke).
267
CHD Risk equivalents
Noncoronary atherosclerotic disease (carotid, PAD, AAA)
DM
CKD
268
most studies have shown that the most significant increase in CHD risk is in patients smoking__ packs daily.
>1
269
Patients with sickle cell disease who have osteomyelitis should receive empiric antibiotic coverage for _____ and _____
Staphylococcus aureus (GP)
- No MRSA: nafcillin, oxacillin, or cefazolin
- MRSA: clindamycin or vancomycin
Salmonella (GN)
-
270
Azithromycin plus ceftriaxone is an appropriate empiric antibiotic regimen for patients who have Sickle cell disease with _______
acute chest syndrome.
271
Nonfunctioning pituitary adenomas generally arise from gonadotropin-secreting cells of the pituitary gland.
Patients usually present with hypogonadism and low gonadotropin levels; serum α-subunit levels are characteristically increased.
Large tumors may cause symptoms directly through mass effect on local tissues. The primary treatment modality is ________
trans-sphenoidal surgery
* Dopaminergic receptor agonists are used for prolactinomas
* Octreotide used for acromegaly (GH adenomas)
272
________ is the most common congenital heart lesion in patients with Down's syndrome.
Echocardiography is the most useful test for diagnostic evaluation of this condition.
Endocardial cushion defect
273
conditions which occur with a higher frequency in Down's syndrome include:
```
Acute Leukemia
Alzheimer-like dementia,
autism,
ADHD,
depressive disorder,
and seizure disorder.
```
274
Which alcohols are associated with fatal intoxications?
Ethylene glycol, ethanol, methanol and isopropanol
275
Ethylene glycol ingestion leads to a severe_________. This causes a typical rapid and deep breathing pattern known as Kussmaul's respiration.
- Treatment?
anion gap metabolic acidosis
Fomepizole
276
__________ puberty is the onset of secondary sexual characteristics in girls age <8 and boys age <9 with advanced bone age and elevated LH and FSH levels.
-Treatment?
Central precocious puberty
GnRH agonist (downregulates LH and FSH)
277
Thelarche = female breast development
Adrenarche = axillary and pubic hair, body odor, acne
Which one is premature in late onset CAH?
premature adrenarche
| not thelarche bc of nl estrogen levels = no premature boobies
278
an acutely inflamed ear canal with purulent drainage and granulation tissue formation.
In an older patient with comorbid diabetes (or other immunosuppressing conditions) this is concerning for ____________
malignant otitis externa (MOE)
- usually begins as a superficial external otitis but progresses rapidly to involve the adjacent bones at the base of the skull.
- tx w/ IV FQ
279
For pts w/ dyspepsia, A trial of a proton pump inhibitor is indicated for patients who ______.
test negative for H pylori
| - However, these medications should not be administered prior to the test because they may reduce its sensitivity.
280
FEV1/FVC ratio is normally 80% what about for below?
- Obstructive lung disease
- Restrictive lung disease
Obstructive lung disease
- low FEV1/FVC <70%
- FEV1 < 80% predicted
Restrictive lung disease
- normal ratio >80%
(both FEV1 and FVC reduced proportionately)
281
Is asthma attack obstructive or restrictive?
obstructive
FEV1/FVC reduced < 70%
FEV1 < 80%
*asthma w/o active sx can show nl PFTs. diagnose w/ methacholine challenge (>20% reduction in FEV1)
282
What are these findings consistent w?
A soft, single second heart sound (S2)
A delayed and diminished carotid pulse ("parvus et tardus")
Loud and late-peaking systolic murmur
severe AS
283
Because pulse pressure (the difference between systolic and diastolic pressure) is directly related to stroke volume, patients with severe AS are unable to create wide pulse pressures. Wide pulse pressures are often seen in patients with ______
aortic regurgitation.
284
A third heart sound is typically caused by blood filling a dilated ventricular cavity in a patient with _____
heart failure.
285
Whats the diff between tick paralysis and Guillain Barre Syndrome?
GBS:
- follows a gastrointestinal or respiratory infection
- typically progresses over several days or weeks
Tick paralysis:
- progresses over 4-7 days
- look for tick on pt
286
Tx for salmonella enteriditis?
nothing - supportive therapy and obs
287
Diff between alcoholic ketoacidosis vs DKA?
| - how do you treat AK?
Alcoholic ketoacidosis has BG < 250 mg/dL
and impaired mental function
- tx: Thiamine and IV fluids
(alcoholics are thiamine deficient until proven otherwise)
288
Patients with gestational diabetes mellitus monitor fasting and either 1- or 2-hour postprandial blood glucose levels.
Target glucose levels are:
Fasting <95 mg/dL
1-hour postprandial <140 mg/dL
or 2-hour postprandial <120 mg/dL
289
Target 2 step approach for screening GDM
- Glucose challenge test at 28 weeks
- 3 hr glucose tolerance test
- Glucose challenge test: BG > 140 -->
| - 3 hr glucose tolerance test
290
Patients with septic abortion have fever, tachycardia, hypotension, lower abdominal pain, and mucopurulent cervical discharge. A septic abortion is a medical emergency managed with ___________
broad-spectrum intravenous antibiotics and surgical evacuation of the uterine contents via suction curettage.
291
_______, a synthetic prostaglandin, causes uterine contractions and expulsion of retained products of conception. It is used in the medical management of spontaneous abortion
Misoprostol
292
________ is used in the management of an ectopic pregnancy in hemodynamically stable patients.
It is NOT used in abortion management
Methotrexate, a dihydrofolate reductase inhibitor
*if a woman wishes to conceive, stop methotrexate 3 mo before pregnany
293
The use of ______ and ______ in early infancy is associated with an increased risk for pyloric stenosis.
erythromycin and azithromycin
- ie: postexposure prophylaxis against pertussis
294
How to treat trichomoniasis in breast feeding mother?
PO metronidazole 2g 1x
| - discard breast milk for 24 hours
295
What happens if you give dextrose prior to thiamine in alcoholics? What symptoms get worse?
Can worsen Wernicke encephalopathy (life threatening thiamine def)
- Encephalopathy - disorientation and confusion
- Oculomotor dysfunction - lateral rectus palsy
- Gait ataxia - wide-based gait or complete gait impairment
296
_______ is a late-stage complication of chronic thiamine deficiency due to repeated or prolonged episodes of Wernicke encephalopathy (WE).
Up to 80% of patients recovering from an acute episode of WE show signs of KS, including significant retrograde and anterograde amnesia, often with confabulation.
- what do you see on MRI?
```
Korsakoff syndrome (KS)
- mammillary body atrophy on MRI of the brain
```
Unlike wernicke encephalopathy, the neurocognitive changes of KS rarely improve
297
Likelihood of type 2 HIT is calculated using the 4 Ts score:
1) Thrombocytopenia - platelets typically decline >30%-50%
2) Timing - onset 5-10 days after heparin initiation or ≤1 day with prior, recent heparin exposure
3) Thrombosis - new thrombosis, progressive thrombosis, or skin necrosis
4) Alternate causes - no other sources for thrombocytopenia are present or likely
298
Raloxifene (Selective estrogen receptor modulators), are associated with an increased risk of venous thromboembolism and should be discontinued ___ weeks prior to any surgical procedure associated with a moderate to high risk of venous thromboembolism.
4 weeks
299
______ are the most common cardiac tumors and can present with signs and symptoms of mitral valve obstruction (eg, diastolic murmur and "tumor plop"), rapidly worsening heart failure, and new-onset atrial fibrillation.
_______frequently embolize systemically, leading to acute _____ occlusion in otherwise healthy patients.
Left atrial myxomas
(apical diastolic murmur)
Myxomas
arterial occlusions
300
How does the dosing of anti-D immune globulin change?
A standard dose of anti-D immune globulin is administered at 28 weeks gestation and again <72 hours postpartum in uncomplicated pregnancies to neutralize occult fetomaternal hemorrhage.
In cases of fetomaternal hemorrhage, the amount of fetomaternal transfusion is calculated, so that an adequate dose of anti-D immune globulin can be administered within the 72-hour timeframe.
301
Kava (treats anxiety/insomnia) and black cohosh (treats hot flashes and vaginal dryness) have which side effects?
hepatic injury
302
Varenicline is a commonly used smoking-cessation agent. It is associated with potential ______ effects and should be avoided in patients with ________
neuropsychiatric
a current unstable psychiatric status or a history of recent suicidal ideation.
303
True/false
Benzodiazepine use is strongly associated with a risk of falls and increased mortality in older patients.
Should you stop it immediately?
True
No, can cause BDZ withdrawal w/ abrupt cessation. Give diazepam IV for treatment of withdrawl
304
______ presents during labor or immediately postpartum with acute onset of hypoxemia, hypotension, and disseminated intravascular coagulopathy.
Treatment is supportive.
Amniotic fluid embolism syndrome (AFES)
AFES is a massive inflammatory response due to the release of fetal amniotic fluid into the maternal circulation.
305
What platelet count does a pt need to have to be on platelet?
>150,000
306
How does transverse myelitis differ from GBS?
| How do you treat each?
a sensory level and bowel/bladder dysfunction after a URI make transverse myelitis (TM) more likely
TM: steroids
GBS: IVIG
307
_______ gangrenosum is most commonly seen in immunocompromised patients with Pseudomonas aeruginosa bacteremia.
Ecthyma
| not pyogenic - seen w/ IBD or arthritides
308
Glucocorticoid administration for __(time?)__ does not typically cause significant suppression of the hypothalamic-pituitary-adrenal axis and can be stopped abruptly with minimal risk of adrenal insufficiency.
<3 weeks
309
Treatment for allergic bronchopulmonary aspergillosis is _________
directed at acutely stopping the underlying inflammation and reducing Aspergillus burden.
Systemic glucocorticoids are the mainstay therapy with consideration of antifungal therapy (itraconazole or voriconazole) to decrease fungal burden and antigenic stimulus.
310
What do you do if AFP levels are high? > 2.5
Repeat AFP, then ultrasound.
If US is nl -> can do amniocentesis for fetal karyotype
311
Anomalous aortic origin of a coronary artery (AAOCA) is a common cause of sudden cardiac death in young athletes.
- Signs?
Patients may have premonitory symptoms of exertional angina, lightheadedness, or syncope.
ECG - normal! (not WPW)
TTE- normal! (not HOCM)
312
Vitamin B12 deficiency may cause ______ and _____ in the bone marrow, which can result in markers of hemolytic anemia and an absent reticulocyte response.
erythroid hyperplasia and ineffective erythropoiesis (impaired DNA synthesis)
Hemolytic anemia sx:
- elevated lactate dehydrogenase
- low haptoglobin
- indirect hyperbilirubinemia
313
orbital cellulitis vs preseptal cellulitis
| - which ones have pain w/ eye movement, proptosis??
orbital cellulitis
314
Dumping syndrome is a common complication of gastrectomy.
- Liquid and food passage through the stomach into the jejunum is faster.
- Abdominal pain, diarrhea, N/V, neurovegetative symptoms such as dizziness, generalized sweating, and dyspnea.
- tx?
Treatment is aimed at decreasing the speed of the passage of fluids and food into the small gut. A high-protein and low-carbohydrate diet is advised, as well as smaller but more frequent meals throughout the day.
315
Tx for pagets disease?
- elevated alk phos
- nl calcium
bisphosphonate
316
Acute rheumatic fever, which presents ___weeks after group A Streptococcus pharyngitis, causes migratory polyarthritis involving the larger joints (eg, knee, elbow). Skin findings include erythema marginatum and subcutaneous nodules.
2-4 weeks
* Parvovirus has symmetric small joint pain
- acute onset (w/in 1 week)
317
______ are vascular anomalies composed of multiple aberrant blood vessels located in the gastrointestinal (GI) tract.
A frequent cause of occult GI bleeding, most common in patients age >60 and are often discovered incidentally on endoscopy, appearing as small, cherry-red lesions. Bleeding rates are higher w/ which diseases?
Angiodysplasias (vascular ectasias or arteriovenous malformations)
Bleeding rates are higher with end-stage renal disease (ESRD), aortic stenosis, and von Willebrand disease (vWD
- most likely cause a bleeding diathesis that leads to more frequent GI bleeding from malformed vessels.
318
Dermatomyositis, an inflammatory myopathy with a characteristic heliotrope rash and Gottron papules, is associated with multiple malignancies, including________
lung,
colon, and
ovarian cancers.
319
Patients with______complain of a "popping" sensation in the knee at the time of injury, followed by development of rapid-onset hemarthrosis and a feeling of joint instability with weight bearing
- diagnose?
partial- or full-thickness tears of the ACL
MRI
320
Patients with ______ knee injury may report a subacute or chronic locking or catching sensation in the knee but often do not appreciate the extent of the injury when it occurs. Effusions, when they occur, typically develop slowly and hemarthrosis is rare.
a meniscal tear
321
```
Iron deficiency labs
MCV
Iron
TIBC
Ferritin
Transferrin (Iron/TIBC)
```
```
MCV - low
Iron - low
TIBC - high
Ferritin - low
Transferrin (Iron/TIBC)- low
```
(only TIBC is high)
322
TIBC is low in ______ and _____
thalassemia and anemia of chronic disease
- Transferrin (Iron/TIBC) is also low
*high in iron deficiency
323
Hemolytic anemia sx:
- elevated lactate dehydrogenase
- low haptoglobin
- indirect hyperbilirubinemia
324
long QT syndrome (QTc >___ msec in men or >___ msec in women)
450 - men
470 - women
325
Restless legs syndromeis characterized by spontaneous, repeated leg movements (to provide relief) in association with unpleasant sensations that occur while at rest.
It is associated with _________.
- What lab should be obtained?
iron deficiency
- Restless legs syndrome may be a symptom of iron deficiency.
Ferritin level is the most accurate measurement of iron stores; levels <75 ng/mL are consistent with clinical symptoms
326
Are headaches an absolute contraindication to Combined hormonal contraceptives?
Yes
due to the increased risk of ischemic stroke
Other absolute contraindications include blood pressure >160/100 mm Hg
and women age >35 who smoke >15 cigarettes per day.
327
The murmur of mitral stenosis is a ______ best heard with the bell of the stethoscope at the ________
soft, low-pitched rumble
cardiac apex, which is located in the fifth intercostal space (between the 5th and 6th ribs) at the left mid-clavicular line.
328
Infants born to mothers with diabetes and poor glycemic control during pregnancy are at increased risk for transient hypertrophic cardiomyopathy with _________ due to excess glycogen deposition in the fetal myocardium.
Tachypnea and respiratory distress may be early signs of ______
a thickened interventricular septum
congestive heart failure.
329
History alone (eg, phone consultation) is usually sufficient for diagnosis of acute uncomplicated cystitis. However, physical examination and urine culture are required for those who __________
are likely to be pregnant (eg, no contraception, no recent menstrual period) or
who likely have pyelonephritis (eg, fever, chills, flank pain) or
vaginal infection (eg, pruritus, discharge)
330
Patients with bicuspid aortic valve are at risk for developing ______________ and should be screened with imaging of the aortic root and proximal aorta.
aortic dilation,
aortic aneurysm,
and aortic dissection,
331
Borrelia burgdorferi moves from the tick gut to the tick salivary glands after _____ hours of attachment.
If duration of tick attachment is unclear, tick ______ is often used as a rough guide
36-48 hours
-As such, a tick attached <36 hours is unlikely to transmit Lyme disease.
engorgement
- transmission risk is low if a tick is unengorged.
332
Ultrasound alone is used to evaluate breast masses in women age ___, as the increased breast density in these patients reduces the sensitivity of mammography.
<30
*In patients age >30, first-line imaging is with MAMMOGRAM due to its ability to further characterize the mass and determine the need for biopsy.
333
Cutaneous cryptococcosis can occur in patients with advanced HIV (CD4 count <100/mm3) and is typically a marker of disseminated disease. Manifestations most commonly include _______
the rapid onset of multiple papular lesions with central umbilication and central hemorrhage/necrosis.
* resembles molluscum contagiosum
- A small area of central hemorrhage or necrosis is an important diagnostic clue.
334
Patients with underlying connective tissue disease are at risk for acute mitral valve regurgitation (MR) due to ______ rupture
Patients with acute mitral valve regurgitation (MR) due to complication of acute MI are more likley to have ______ rupture
chordae tendineae
papillary muscle rupture
335
Marfan syndrome shares many features with EDS. Both diseases can cause scoliosis as well as myxomatous mitral valve degeneration and chordae tendineae rupture, leading to acute MR.
- However, skin findings are much MORE prominent in ______
Elhers danlos
| - easy bruising, velvety w/ atrophy scarring
336
Hypercalcemia is sometimes seen in which one, Total Parenteral Nutrition or Enteral Feedings?
TPN
337
___________ should be suspected in healthy adolescent patients with upper extremity morning myoclonus and subsequent generalized tonic-clonic seizures.
Electroencephalogram classically demonstrates _______ during the interictal period. First-line treatment is valproic acid.
Juvenile myoclonic epilepsy
bilateral polyspike and slow wave discharges
338
RAI scan and Thyroglobulin levels in exogenous hormone intake
Low RAI: thyroid follicular activity suppressed
Low thyroglobulin (which is released by nl thyroid follicules): also low d/t suppressed follicular activity
339
Toxic adenoma
Multinodular goiter
and Graves disease
What is the RAI?
high
Nodular pattern:
- Toxic adenoma
- Multinodular goiter
Diffuse pattern:
Graves disease
340
Obtaining a _______ helps in determining the predominant pathophysiologic mechanism of normocytic/normochromic anemia.
reticulocyte count
Differentiate btwn
1) diseases with decreased red blood cell production, and
2) hemolytic disorders.
341
Dysphagia initially involving both solids and liquids would suggest a __________ disorder, but dysphagia that occurs initially for solids and later includes liquids is characteristic of __________
neuromuscular
mechanical obstruction
342
Structural lesions that lead to dysphagia in the pharynx and upper esophagus may be visualized with ___________
nasopharyngeal laryngoscopy (minimally invasive)
* EGD is most helpful when a patient has lower-esophageal symptoms.
343
adenocarcinoma (AC) and squamous cell carcinoma (SCC).
| The location in the esophagus?
adenocarcinoma (AC)
- Mid-Distal esophagus, mostly d/t GERD and Barretts
squamous cell carcinoma (SCC).
- Upper-esophageal mostly d/t alcohol and tobacco
344
The serum calcium concentration decreases by ____ for every ____ decrease in the serum albumin concentration (nl = 3.5)
0.8 mg/dL
1 g/dL
345
Sodium-glucose cotransporter 2 inhibitors reduce glucose levels by promoting renal glucose excretion and are associated with which side effects?
vulvovaginal candidiasis, urinary tract infections, and polyuria.
346
Mallory Weiss Vs Boerhaave
- both are associated w/ forceful retching
- Where is the tear?
- What is the cardinal sign?
- Imaging?
Mallory weiss
- Mucosal tear
- hematemesis (bright red or coffe ground)
- Upper GI endoscopy
Boerhaave syndrome
- Transmural tear
- Crepitus, crunching sound
- ESOPHAGOGRAPHY or CT w/ water sol contrast
- EMERGENCY SURGICAL CONSULT
347
Combination oral contraceptives (Increase/decrease) the risk of ovarian and endometrial cancer.
Decrease
348
GBS prophylaxis intrapartum is given if Unknown GBS status plus any of the following: (3)
1. Preterm delivery (eg, <37 weeks gestation)
2. Rupture of membranes for >18 hours at any gestational age
3. Intrapartum fever (eg, chorioamnionitis)
349
______ is an oropharyngeal infection caused primarily by Coxsackie group A virus.
It is usually seen during the summer in children age 3-10, who present with fever, drooling, sore throat, decreased appetite, headache, and painful posterior pharyngeal vesicles.
Herpangina
| HSV can cause gingivostomatitis in children - vesicles on anterior oral mucosa
350
________ is a sudden and transient monocular blindness.
- marker of carotid artery atherosclerotic disease that is usually advanced. Physical examination will often reveal a _____________
Amaurosis fugax
- Carotid bruit.
Carotid Doppler evaluation is necessary to evaluate the extent of the disease and to assess the need for a carotid endarterectomy.
351
Young patients with diabetes, osteoporosis, hypertension, and hypokalemia should be screened for ______
can be performed by an overnight dexamethasone suppression test or measurement of 24-hour urinary free cortisol level.
Cushing's syndrome.
352
_________ is a degenerative disease that affects the elderly population.
- It is characterized by increased lumbar pain on extension of the spine.
- The pain usually improves when the patient sits down or when he bends forward (e.g., when using a grocery cart).
Lumbar spinal stenosis
* Disc herniation pain worsens with lumbar flexion.
353
________ hyperglycemia is a potential complication of severe illness (eg, sepsis). It is associated with increased morbidity risk and is caused by high circulating stress hormones (eg, cortisol, catecholamines).
- Hyperglycemia
- Ketoacidosis
Stress hyperglycemia
*do not meet criteria of diabetes (>200 random WITH symptoms of diabetes)
354
Traumatic lumbar puncture (LP), which results from accidental damage of a blood vessel during the procedure.
- A RBC count exceeding ____/mm3
- WBC elevation in traumatic LP is commonly explained by the blood leak if approximately ______WBC present.
- protein and glucose level typically high.
6,000 RBC
one WBC is present per 750-1000 RBCs.
355
Tx of mild cholecystectomy vs severe cholecystectomy
mild cholecystectomy: lap chole w/in 7d
severe cholecystectomy (organ failure, hypotension not responsive to fluid): wait for resolution of active inflammation and eval biliary system via ERCP
356
_________ usually manifests as lateral shoulder pain aggravated by movements requiring abduction and external rotation of the shoulder
Rotator cuff tendonitis
357
Patients with a history of renal disease, diabetes mellitus, hypertension, or prior preeclampsia are at high risk for preeclampsia recurrence.
In high-risk patients, _______ is used for preeclampsia prevention and is started at 12 weeks gestation.
aspirin
358
The major problem that leads to difficulties finding cross-matched blood in patients with a history of multiple transfusions is _________.
alloantibodies
359
The isolated gastric varices, which are the hallmark of ___________
splenic vein thrombosis
- venous blood flow is redirected from the splenic vein to the collateral gastroepiploic system and short gastric veins.
- Patients with chronic SVT may also develop left-sided portal hypertension (due to isolated pressure increases in the splenic portion of the portal system), ascites, and congestive splenomegaly with associated features of hypersplenism
(eg, anemia, thrombocytopenia).
360
___________ is a potential complication of cirrhosis (rather than pancreatitis). Its presentation can be similar to SVT, but in portal vein thrombosis there is hypertension of the entire portal system with ESOPHAGEAL varices typically accompanying GASTRIC varices!
Chronic portal vein thrombosis
361
Asymptomatic subclinical hypothyroidism does not require treatment. Treatment is warranted in the presence of:
antithyroid antibodies
an abnormal lipid profile
362
Acute stress disorder vs PTSD?
ASD: < 1 mo
PTSD: >1 mo
363
___________ is associated with the highest increase in risk for pelvic inflammatory disease (PID).
#1 Having multiple sexual partners (20 fold)
Other risk factors include being age 15-25, previously having PID, inconsistently using barrier contraception, and having a partner with a sexually transmitted infection.
364
Single-item screening for alcohol abuse?
How many times in the past year have you had 5 (4 for women) or more drinks in a day?
365
The symptoms of ______ poisoning include flushing, a throbbing headache, palpitations, abdominal cramps, diarrhea, and oral burning.
- These typically begin 10-30 minutes after ingesting the fish, and are self-limited.
scombroid
*easily mistaken for acute allergic reaction
366
_______ presents with elevated creatinine, hypertension, and hematuria with dysmorphic red blood cells (RBCs), RBC casts, and proteinuria.
Acute glomerulonephritis
367
Papillary necrosis associated Nephropathy shows which type of casts?
WBC casts
368
Entamoeba vs hydatid cyst
Entamoeba: grows 8-20 weeks (anchovy paste amoeba abscess)
Hydatid cyst: tapeworm - grow slowly over years
369
Asymptomatic Child swallows a coin
- < 24h
- >24 h
- unknown time of ingestion
- < 24h: observe, repeat xray in 12-24h
- >24 h: urgent endoscopy
- unknown time of ingestion: urgent endoscopy
*Coins lodged >24h are sig risk of complications (erosions, perf)
370
High pitched bowel sounds
SBO caused by incarcerated bowel/hernia
| - surgery
371
How many cafe au lait macules are present in NF1?
>6
372
Regardless of LDL, all pts <75 w/ established CV disease should be treated w/ ______
high intensity statins (atorvastatin 40-80mg or rosuvastatin 20-40mg)
373
Leading cause of erythema multiforme
Infection - mostly HSV
*erythema marginatum caused by strep pyogenes
374
When women >30 w/ palpable breast masses are evaluated via diagnostic mammography, but end up being benign or indeterminate, what do you do?
U/S to further characterize mass
375
Pulmonary effects of bleomycin?
Pulmonary fibrosis
376
A liver mass in pt w/ HBV and chronic liver disease in an alcoholic is concerning for _______, Which originates from _____
hepatocellular carcinoma - originates from hepatocytes - liver parenchyma
377
Low risk prostate cancer if gleason score is ____
<6
*but still need DRE and PSA check and prostate bx every 6 mon- year
378
Sandblasting is a risk factor for silicosis but typically presents how?
b/l small round nodules in upper lobes
*do not confuse with sarcoidosis - hilar lymphadenopathy and ground glass opacities and bronchovascular irregularities - NONcaseating granuloma
379
Contraindications for short term (3-5 years) estrogen/progesterone hormone therapy to treat menopausal sx?
```
Coronary heart disease
Active liver disease
h.o Breast ca
VTE
Stroke
```
380
Herpes zoster vaccine (shingles) recommendations
immunocompetent adult >60
*lifetime risk >25% and increases w/ age
381
Oral advanced directive can be honored if a pt has a terminal/irreversible condition if?
declared to attending physician in presence of 2 witnesses
382
nl PT and prolonged aPTT is indicative of a _____ disorder
intrinsic pathway (ie: hemophilia A and B, vWD, antiphospholipid ab, Antibodies to VIII, IX, and XI)
383
tx of aflutter?
Cardioversion or cardiac ablation
- comparable to afib: need anticoagulans >3weeks prior to cardioversion
384
Biventricular pacemaker vs Implantable cardioverter-defibrillator
Biventricular pacemaker
- LVEF <35% and QRS duration >120msec
Implantable cardioverter-defibrillator (ICD)
- Prior MI and LVEF <30%
- HF and LVEF <35%
385
_______ should be suspected in any young healthy pt who has a blood clot w/o any underlying ppt factor
inherited thrombophilia
| - #1 activated protein C resistance caused by factor V leiden
386
Wide QRS = > ___ms
Treat TCA overdose if QRS interval > ___ ms or ventricular arrythmia
>120 ms
>100ms sodium bicarb
387
Initial medication tx options for obese pts who fail lifestyle modifications
Orlistate (inhibit pancreatic lipases = less fat absorption)
388
Pt w/ bloody diarrhea, animal contact / meat ingestion and triad of
1) ARF
2) Microangiopathic hemolytic anemia
3) thrombocytopenia
Hemolytic uremic syndrome from EHEC E.coli 0157H7
389
Pts on immunosuppressive agents after kidney transplant are at risk for developing nephritis as a result of infection from ______.
- bx findings include
BK-virus, a polyomavirus
Renal tubular damage and prominent basophilic intranuclear intrusions
Tx: decrease the immunosuppession
390
Delivery in pts w/ Maternal hyperglycemia
| - expectant?
deliver at 39 weeks gestation
If fetus is >9.9lbs, that is an indication for C-section
391
Myopathy occurs in ____% of pts w/ hypothyroidism
1/3
| - can range of asympto elevation in CK -> rhabdo
392
Ergots and triptans are good for migraine abortants, what is first line prophylaxis?
BB (metoprolol)
TCA (amitriptyline)
Anticonvulsants (valproate)
393
tx of pts w/ candida vulvovaginitis
- nonpregnant
- pregnant
Nonpregnant: PO fluconazole
Pregnant: vaginal clotrimazole, miconazole, nystastin
394
_______ is used to treat depression in pts w/ dementia and stroke
citalopram
395
Gold std eval of focal sz
MRI brain
| - may be 2/2 to structural abnormality (ie tumor, esp if they have H/A)
396
____________ is a systemic vasculitis that involves the upper (bloody nose) and lower respiratory tract (hemoptysis) and the kidneys (hematuria)
granulomatosis w/ polyangiitis (wegeners)
397
Lithium will cause nephrogreneic diabetes insipidus which typically presents as
Polyuria
Polydipsia
Nocturia
*NOT hyperglycemia and elevated HbA1C
398
Second gen antipsycotics are often used to augment antidepressants in pts w/ tx resistant depression.
- How does the side effects of metabolic effects present?
weight gain and new onset DM
399
Immediate admin of ____ in pts w/ suspected hypoplastic L heart syndrome is needed
PGE1
- ductal DEPENDENT congenital heart valve (underdevel L V and aorta)
400
What does rising anti-Rh(D) antibody titers mean in a pregnant mom?
pt has already undergone alloimmunization
- what we are trying to PREVENT with anti-D immune globulin
- significant risk of hemolytic disease - eval fetus for anemia and hydrops fetalis
401
Which is associated more with OSA, neck circumference or body weight?
neck circumference
402
Congenital umbilical hernia that is reducible and asymptomatic?
- what do you do?
obs and reassurance
| - very UNLIKELY to incarcerate or strangulate
403
_____ presents with hypoglycemia, macrosomia, macroglossia and hemihyperplasia
beckwith wiedemann syndroe
404
knee joint aspiration
- < 2000 cells
- 2000 - 75,000 cells
- > 100,000 cells
OA - < 2000 cells
RA/Gout - 2000 - 75,000 cells
Infectious arthritis - > 100,000 cells
405
Why do we treat VZV w/ antivirals w/in 72h?
decrease the risk of postherpetic neuralgia (complications)
*it will not prevent spread
406
The femoral hernia passes below the ____ and is medial to the ___________
below inguinal ligament
medial to femoral NAV (lateral to medial)
407
when do you work up infertility?
women age < 35, no pregnancy in > 12 mo
women age >35, no pregnancy in > 6 mo
408
Deep tendon reflexes in pts with GBS?
What about pts with MS?
GBS: diminished or absent (think everything is weaker)
MS: hyperreflexia, positive babinki, UMN
409
NSAIDs and glucocorticoids are helpful in reducing pain and inflammation in RA, but only ______ can alter long term course of disease
cytotoxic meds (DMARDS)
- nonbiologic (hydroxychloroquin and methotrexate)
- biologic agent (TNF-a inhibitors, rituximab)
410
Tx of acute gout
Prevention of gout
tx: high dose NSAIDs (indomethacin), or colchicine or steroids if contraindication to NSAID
prevent: allopurinol
* Always Avoid Allopurinol in Acute Attacks
411
______ is indicated for pts w/ recurrent gouty attacks. However, pts should recieve ______ to prevent acute gout during initiation and titration.
Urate lowering drug (allopurinol)
Cholchicine or NSAIDS
412
Postpartum thyroiditis: autiimmune inflammation of thyroid follicles and release PREFORMED thyroid hormones
- tx?
BB
*Cant use methimazole bc it inhibits the synthesis of thyroid hormone
413
_____ and ____ are associated w/ TPO antibody assays
Postpartum thyroiditis and silent thyroiditis
- both are variants of Hashimotos!
414
Radiation induced cardiotoxicity include
coronary disease
MI
Restrictive cardiomyopathy with DIASTOLIC dysfunction
valvular abnormalities
415
NONejection click followed by systolic mumur dependent on body positioning
Mitral valve prolapse
416
low pitch mid diastolic murmur heard best at cardiac apex
| - opening snap heard after S2
mitral stenosis*
417
Ejection click followed by mid-late constant systolic murmur (not crescendo- decrescendo)
mitral regurg
418
peripheral smear for:
Infectious mononucleosis 2/2 EBV
Leukemia
Hodgkin disease
atypical lymphocytes
Blasts
Reed sternberg cells
419
Tx of BPH (urge incontinence, poor bladder emptying)
Tx of urgency incontinence
terazosin
- (alpha 1 antagonist)
Tolterodine, oxybutinin, solifenacin,
- (antimuscarinic - inhibit detrusor muscle contraction)
420
______ is characterized by pain, redness, variable vision loss, constricted and irregular pupil
- diagnosed w/ visualization of leukocytes in anterior segment
anterior uveitis (iritis)
421
Psychotic symptoms lasting >2 weeks in the ABSENCE of major depressive or manic episode
- Throughout lifetime
Schizoaffective disorder
*note that in bipolar and Major depression w/ psychotic symptoms, the psychotic sx occur EXCLUSIVELY during mood episodes.
422
Which one has the presence of mood symptoms lasting a significant portion of the illness, schizoaffective disorder or schizophrenia?
Schizoaffective disorder
- moody
*the moodiness in schizophrenia are brief
423
__________ is a well known complication of GERD that results in dysphagia (solids -> liquids), lack of alarm sx
peptic esophageal stricture
424
Can drug induced lupus cause renal failure?
no
425
tx for infant botulism
IV botulism immune globulin ASAP
| - hospitalized -> full recovery
426
Menopause is a clinical diagnosis, do you need to do anything when diagnosing?
Yes - endometrial bx in women >45 w/ anovulatory bleeding to eval for endometrial hyperplasia/cancer
427
Normal HBV vaccine schedule
| - what if infant was exposed at birth?
nl: age 0, 2, and 6 months
exposed: HB vaccine + immunoglobulin w/in 12 h
428
Colon cancer screening
- Gen pop
- First degree relative >60
- First degree relative < 60
Start screening at age 50
- Colonoscopy q10y
- FOBT or FIT qy
Colonoscopy at age 40 or 10 years b4 age of Ca dx, which ever comes first
- repeat q3-5 years
429
Tx for dementia w/ lewy bodies - why do we give
- Cholinesterase inhibitors
- Carbidopa-Levodopa
- Antipsychotics
- Cholinesterase inhibitors: cognitive impairment
- Carbidopa-Levodopa: parkinsonism
- Antipsychotics: hallucinations or delusions
*be aware that DLB pts are very sensitive to first gen antipsychotics and should be given 2nd gen instead (risperidone)
430
Pancoast tumors / Superior Pulmonary Sulcus tumor (NSCLC) has a __% chance of spreading to the spinal cord
25%
- SC compression can result in paraplegia
- Need early recognition and corticosteroids, surgery, radiation
431
Meconium ileus is the earliest manifestation of ______ and is pathognomonic for it
- can result in dilated loops of small bowel, R sided "ground glass" mass d/t mixing if air bubbles w/ meconium
cystic fibrosis
| - fam h.o sinus infections
432
In newborn infants, up to ___% weight loss is expected within ___ time
10% within first week
| - f/u 2-3 days
433
Adverse events in hospitals
```
#1: adverse drug events
#2: Hosp acquired infxns
```
434
Intrinsic sphincter deficiency is seen in ____ urinary incontinence
stress
| - as well as urethral hypermobility
435
_____ incontinence presents w/ constant dribbling of urine d/t bladder distension from incomplete emptying
overflow
| - PVR >150 mL
436
high Serum-Ascites Albumin (SAAG) (>1.1 g/dL) indicate
Presence of portal HTN:
congestive heart failure
cirrhosis
and alcoholic hepatitis
437
Low Serum-Ascites Albumin (SAAG) (>1.1 g/dL) indicate
absence of portal hypertension.
```
peritoneal carcinomatosis,
peritoneal tuberculosis,
nephrotic syndrome,
pancreatitis,
and serositis.
```
438
The most common cause of mitral stenosis (loud first heart sound, low pitch mid diastolic rumbling murmur heard best at cardiac apex) is _____
rheumatic heart disease, with symptoms presenting 10-20 years after initial rheumatic fever.
439
The cremasteric reflex is regulated at the ____ level of the spinal cord. This reflex can be diminished or lost secondary to diabetic autonomic neuropathy.
L1-L2
| - also responsible for hip flexion and adduction
440
HVC
- Screening?
- diagnostic test?
HCV antibody testing
HCV Nucleic Acid Testing (NAT)
- if + then candidate for treatment
441
If female pt has primary amenorrhea and no uterus, which two disorders can be present?
Abnormal mullerian development
- 46, XX
- nl female testosterone levels
or
Androgen insensitivity syndrome
- 46, XY
- nl male testosterone levels
442
Which one has normal secondary sex characteristics (pubic/axillary hair), mullerian agenesis or AIS?
Mullerian agenesis
| - even if uterus is not present, ovaries are!
443
_______ presents in phenotypical females with primary amenorrhea and absent pubic/axillary hair but normal breast development.
Androgen insensitivity syndrome
| - nl breast development bc excess testosterone is aromatized to estrogen
444
_________ is a complication of an unrepaired ventricular septal defect that leads to pulmonary hypertension, right-to-left shunting, cyanosis, and eventual right- and left-sided heart failure.
- how does pregnancy affec this?
Eisenmenger syndrome
- pregnancy decreases systemic vascular resistance and exacerbates R->L shunting and worsens cyanosis and HF
- absolute contraindication to pregnancy: up to 50% maternal mortality
445
Murmurs that become louder with increased venous return
HOCM
MVP
446
What do you have to test for before starting TNF inhibitors (infliximab, etanercept)?
Pts are at increased risk for opportunistic infections - especially reactivation of TB
- Get skin test or Interferon gamma release assay
447
Methotrexate is first line for treating RA. What is second line if it doesnt work?
TNF inhibitors (infliximab, etanercept, adalimumab)
448
____________ is a neutrophilic dermatosis that is usually associated with inflammatory bowel disease or an arthritides.
- Lesions typically begin as inflammatory nodules, pustules, or vesicles and quickly evolve to ulcers;
- usually quite painful
Pyoderma gangrenosum
449
_________ is most commonly seen in immunocompromised patients with Pseudomonas aeruginosa bacteremia.
- Manifestations typically include the rapid evolution of >1 skin lesion from an erythematous macule to a yellow-green pustule or bullae and then into a nonpainful gangrenous ulcer.
- Fever and systemic signs of illness are common.
Ecthyma gangrenosum
- treat with pip/taz and AG
- no need for surgery
450
Prior to treating acute cystitis in a sexually active woman of reproductive age with antibiotics what do you need to do?
a urine pregnancy test is indicated to exclude pregnancy and to avoid the possibility of fetal exposure to a teratogenic medication.
451
_________ presents with recurrent exertional pain in the muscles within a fascial compartment (usually in the lower leg), brought on by a strenuous endurance exercise regimen.
- The symptoms resolve with rest, do not occur during normal activity, and examination findings are typically normal.
chronic exertional compartment syndrome
452
In rhabdomyolysis, _______ from Myoglobin degradation is directly toxic to proximal tubular cells.
how?
Heme pigment
- Combines with Tamm-Horsfall protein to form tubular casts
- Induces vasoconstriction, reducing medullary blood flow
453
__________ is a common cause of acute renal failure in patients with cirrhosis but should be considered a diagnosis of exclusion.
How to confirm?
How to treat?
Hepatorenal syndrome
A fluid bolus is needed to confirm that the renal failure is not secondary to intravascular volume depletion.
- midodrine + octreotide + albumin
454
Adrenal Mass
| - essential laboratory studies
1. serum electrolytes,
2. dexamethasone suppression testing,
3. 24-hour urine catecholamine,
4. metanephrine,
5. vanillylmandelic acid
6. 17-ketosteroid measurement.
455
Surgical excision of an adrenal mass is recommended for __________.
- all functional tumors,
- all malignant tumors (which demonstrate a characteristic heterogenous appearance on imaging),
- all tumors greater than 4 cm.
456
most common cause of postpartum fever
- fever and uterine fundal tenderness >24 hours after a cesarean delivery
- How do you treat?
postpartum endometritis
- clindamycin plus gentamicin.
* Clindamycin covers aerobic gram-positive cocci and penicillin-resistant anaerobes.
* Gentamicin covers gram-negative and some gram-positive bacteria (eg, Staphylococcus).
457
__________is a broad-spectrum regimen commonly used for chorioamnionitis, an intrapartum uterine infection.
Ampicillin plus gentamicin
*does not cover penicillin-resistant anaerobes
458
Studies have estimated the cardiovascular exertion of sexual activity to be relatively modest, in the range of 3-4 metabolic equivalents.
- what is that ~ equal to?
household chores
MI patients who have undergone successful revascularization or have no evidence of ischemia on exercise testing can be considered low-risk.
They may safely resume sexual intercourse soon after the MI, within 1-4 weeks
459
_____ drug is recommended for upper GI bleeding due to variceal hemorrhage.
Octreotide
460
What is considered an adequate trial for antidepressant meds?
6 weeks
461
As the baby progresses from the uterine cavity to the perineum, what happens to the fetal stations?
It increases
-5, -4, -3, -2, -1, 0 --> +1, +2, +3, +4, +5
462
When is an operative vaginal delivery performed?
during the second stage of labor (when the cervix is 10 cm dilated) to expedite delivery for protracted labor, fetal heart rate tracing abnormalities, or maternal exhaustion.
463
What vaccines can be given to HIV + pts if they have no evidence of immunity and their CD4+ counts are < 200?
Live: MMR, VZV,
HBV, HAV,
13-valent pneumococcal vaccine (PCV13) and 23 valent pneumococcal (PPSV23) polysaccharide vaccine
*do NOT give intranasal influenza
464
Psychiatric symptoms are commonly seen in patients taking corticosteroids and can include mood changes, psychosis, and anxiety.
- The symptoms occur more commonly in patients taking high doses for prolonged periods, but they can occur at any time.
The first step in treatment is ?
dose reduction of the offending corticosteroid.
| - then you can treat psych conditions if they persist
465
primary means of treatment for infectious mononucleosis (IM) is?
- What happens in the rare care that an airway obstruction is imminent?
supportive care + Acetaminophen or NSAIDs provide some symptomatic relief but do not shorten the duration of illness.
Corticosteroids
466
Indication for prophylactic admin of anti-D immunoglobulin for Rh(D)-negative patients
- which week of gestation?
at 28-32 weeks
ectopic pregnancy
external cephalic version
CVS sampling, amniocentesis
Hydatidiform mole
+ w/in 72h of any trauma/risk of bleed
467
Lung cancer screening with low dose CT is recommended every ____ years for patients age 55-80 with a >30-pack-year smoking history and who currently smokes or quit within the last 15 years.
Screening is associated with a 20% relative reduction in mortality risk but a false positive rate of nearly___
q1y
96%.
468
At _____ weeks gestation, all pregnant women should undergo screening for anemia with a hemoglobin/hematocrit or a complete blood count (which can be compared to results from the initial prenatal visit).
24-28
Physiologic anemia occurs in most pregnancies secondary to an expanding plasma volume that is disproportionate to the increase in red blood cell mass.
Iron requirements increase in pregnancy; treatment of physiologic anemia is with iron supplementation.
469
Gestational diabetes mellitus screening is performed at _____ weeks due to the rise in human placental lactogen, a hormone secreted by the placenta that increases fetal glucose supply by inducing maternal insulin resistance.
24-28
470
Indications for platelet transfusion include:
- a platelet count ______,
- active bleeding with a platelet count ______
- planned major surgery with a platelet count _______
- a platelet count <10,000/mm3,
- active bleeding with a platelet count <50,000/mm3,
- planned major surgery with a platelet count <50,000/mm3.
471
Neuraxial analgesia provides the most effective pain relief for laboring patients with a low risk of adverse effects.
Contraindications include severe thrombocytopenia (platelet < _______) or a _______ due to the risk of spinal epidural hematoma.
<70,000/mm3
rapidly dropping platelet count (often associated with preeclampsia with severe features).
472
Pre-renal AKI vs ATN
| - BUN/Cr ratio?
Prerenal
>20
ATN
nl: 10-15
Response to a fluid challenge is the gold standard in distinguishing prerenal azotemia (which responds to a fluid challenge with improved urine output) from ATN.
473
Red cell casts in the urine are indicative of ________
glomerulonephritis.
474
Systemic side effects and neurotoxicity is one of the major limitations to the use of phenytoin.
Phenytoin toxicity.
The earliest sign is the presence of ________. Some other effects include _____.
nystagmus on far lateral gaze
blurred vision, diplopia, ataxia, slurred speech, dizziness, drowsiness, lethargy, and decreased mentation -> coma.
- (like alcohol)
475
```
Actinic keratosis (AK) lesions are d/t?
Untreated AK has up to a 20% risk of progression to _____.
- How do you treat?
```
chronic sun exposure
squamous cell carcinoma.
- if a lot: field treatment is 5-fluorouracil cream
- if just a couple: cryosurgery or surgical excision
476
tx of seborreic dermatitis d/t greasy scalps and fungus -
use selenium sulfide shampoo
477
Rosacea typically presents with facial erythema and edema (can look like lupus), often with telangiectasias, papules, pustules, and localized tissue hyperplasia.
- treatment?
doxycycline
478
_______ would be appropriate for a confirmed diagnosis of narcolepsy.
stimulant - modafinil
479
History of excessive daytime sleepiness, risk factors of Male, hypertension, and obesity.
- How do you diagnose?
Obstructive sleep apnea
| - Polysomnography followed by multiple sleep latency test
480
Malabsorption syndromes w/ high osmotic gap
Lactose intolerance
Celiac disease
481
villous atrophy, loss of the normal villus architecture,
intraepithelial lymphocytic infiltrates,
and crypt hyperplasia.
Celiac disease
| - needs dietary mod
482
TTP is an acquired syndrome due to the formation of autoantibodies against ______, a plasma metalloprotease responsible for cleaving ultralarge strings of ______ off the vascular endothelial wall.
ADAMTS13
von Willebrand factor (vWF)
483
Uncleaved chains of _______ on the vascular endothelial wall trap and activate platelets, resulting in severe thrombocytopenia and microangiopathic hemolytic anemia (eg, schistocytes, elevated indirect bilirubin).
- Urgent treatment ?
von Willebrand factor (vWF)
plasma exchange removes the autoantibody and replenishes ADAMTS13 (plasma metalloprotease)
484
Immune thrombocytopenia vs thrombotic thrombocytopenic purpura (TTP)?
immune thrombocytopenia is NOT associated with MAHA (shistocytes and elevated indirect bili, lac dehydrogenase, and aminotransferases).
485
Hypoxemia in chronic obstructive pulmonary disease (COPD) is primarily caused by _______.
The emphysematous component of COPD causes______ due to loss of elastic tissue and small bronchiolar collapse
ventilation/perfusion (V/Q) mismatch.
- mismatch is worsened during exacerbation
airflow limitation
486
How does supplemental O2 improve hypoxemia in pts w/ COPD?
Supplemental oxygen improves hypoxemia by increasing oxygen exchange in lung regions that have a low V/Q ratio.
These poorly ventilated lung regions (low V/Q regions) undergo hypoxic vasoconstriction to improve overall gas exchange efficiency.
Despite restricted airflow, supplemental oxygen (O2) is able to successfully reach the alveoli in these regions, resulting in an increase in Q (due to alleviation of hypoxic vasoconstriction) and improved gas exchange to the blood (improved hypoxemia).
487
The natural history of tuberous sclerosis complex (TSC) is progressive, and ______ is the leading cause of death in patients with TSC.
For these reasons, ______ and ______ should be obtained when TSC is initially diagnosed.
neurologic impairment
a brain MRI (hamartomas) and electroencephalogram (sz)
488
CSF analysis - high protein, low glucose, low leukocyte
viral infection or fungal infection (cryptococcal meningitis if lymphocytic predominance)
489
Patients with HIV who have cryptococcal meningitis require treatment in 3 stages as follows:
Induction - amphotericin B and flucytosine for >2 weeks (until symptoms abate and CSF is sterilized)
Consolidation - high-dose oral fluconazole for 8 weeks
Maintenance - lower-dose oral fluconazole for >1 year to prevent recurrence
*Antiretroviral treatment should generally be initiated 2-10 weeks after beginning treatment for meningitis.
490
Occular lesions, what is considered small?
| - what do you do if large?
<10 mm diameter
<3mm thickness
- radiation therapy
491
Postpartum blues vs Postpartum depression vs
Postpartum blues: < 2 weeks
| Postpartum depression: > 2 weeks
492
Can you breastfeed on antidepressants?
yes
- Sertraline and paroxetine safest
*Patients who were treated with antidepressants during pregnancy up until delivery should be maintained on the same medication that was prescribed before delivery.
493
11 B-hydroxylase vs 17 a-hydroxylase?
11 B-hydroxylase
- Ambiguous genitalia in girls
17 a-hydroxylase
- All pts phenotypically female
*both have HTN, fluid and salt retention (opp of 21-hydroxylase)
494
All patients with congenital adrenal hyperplasia require chronic ______ replacement to maintain blood pressure and growth and to suppress adrenal androgens.
glucocorticoid and mineralocorticoid
*remember, these pts present with hypotension, unlike 11, and 17- hydroxylase
495
MS exacerbations in pregnant patients is treated w/ ________as they are generally well tolerated and are not associated with teratogenicity
short-term intravenous glucocorticoids
*In nonpreg pts, treat w/ PO or IV corticosteroids
496
chronic maintenance therapy in patients with relapsing-remitting multiple sclerosis (MS)
Disease-modifying drugs (eg, beta-interferon, glatiramer acetate)
*exacerbations are treated w/ corticosteroids
497
First-line treatment for severe spasticity includes _____ or _____
oral baclofen or tizanidine.
498
______ is an emollient cream approved by the FDA for reduction of fine wrinkles, mottled hyperpigmentation, and roughness of the facial skin.
- Also good at reducing actinic keratoses and in improving the appearance of brown spots, regardless of etiology.
Tretinoin ( all-trans-retinoic acid)
499
Opioid withdrawal can be managed with _______ and _____
opioid agonists (methadone, buprenorphine)
or
nonopioid agents such as clonidine
* decision is related to the treatment setting
Opioid agonists requires high levels of regulation in a supervised program
500
solitary pulmonary nodule
- what is the size? What is likely to be malignant?
- when do you work it up with CT?
< 3 cm
if > 0.8cm, intermediate - high probability of malignancy
if it changes in size, or appearance, or no prior imaging is available
501
Tx for solitary pulmonary nodules?
Depends on probability of malignancy:
High malignant probability, > 0.8cm, high risk pts, spiculated appearance
- timely surgical excision is most appropriate; thoracotomy or video-assisted thoracoscopy (VATS) can be both diagnostic and curative.
Low risk <0.6cm, repeat CT in 3 mo
502
High risk autoimmune pt.
Involvement of the posterior column (loss of proprioception),
lateral column (brisk reflexes),
and peripheral nerves (loss of ankle jerks)
Indicate neurologic involvement due to ______________
vitamin B12 deficiency, which resulted from atrophic gastritis (pernicious anemia)
- deficiency of intrinsic factor secreted by the stomach
503
Treatment with vitamin B12 in patients with moderate to severe megaloblastic anemia can cause______
Hypokalemia - severe and life-threatening.
| - results following the uptake of potassium by newly forming red blood cells.
504
As patients recover from acute hepatitis B virus (HBV) infection, there is normally a steady drop in both aminotransferase and HBV DNA levels and clearance of hepatitis B surface antigen within _____
6 months
- repeat labs q3mo
*Hepatitis B vaccine and hepatitis B immune globulin are usually administered as postexposure prophylaxis to health care workers exposed to contaminated blood or other body fluids
505
Acute HBV infection:
- Patients infected at age 1-5 have a ____ progression rate to chronic HBV infection,
- Adults have a progression rate of ____
20%-50%
under 5%
506
Acute pancreatitis vs Chronic pancreatitis?
acute pancreatitis can be effectively diagnosed with elevations in serum lipase or amylase,
chronic panc does not regularly result in laboratory abnormalities
- need magnetic resonance cholangiopancreatography (MRCP)
- Pancreatic calcifications are the hallmark of CP
507
Diabetic neuropathy should be suspected in patients with diabetes who have symmetric sensory changes in the feet that consist of injury to nerve fibers controlling __________________________
pain,
temperature,
vibratory, and
proprioception sense.
508
Lead toxicity in homes prior to 1978
- Screening?
- Confirmation?
- What is toxic level?
- Screening: fingerstick (capillary) testing
- Confirmation: venous lead level
Mild intoxication (<45 μg/dL) require extensive counseling on cognitive impairments and behavioral problems that can persist into adolescence
Severe intoxication (>45 μg/dL) requires chelation therapy (succimer)
509
Triad of manifestations:
Palpable purpura
Weakness
Arthralgias
mixed cryoglobulinemia syndrome
- Most cases arise in those with chronic hepatitis C virus
Labs
- elevated rheumatoid factor and hypocomplementemia.
Approximately 20% of patients develop glomerulonephritis (red cells, red cell casts, proteinuria) with or without renal insufficiency.
510
Mixed cryoglobulinemia syndrome is typically treated with______
immunosuppressive therapy (eg, corticosteroids and rituximab)
followed by targeted therapy against the underlying condition
- ie: Antivirals against hepatitis C virus (the most common trigger)
511
Lyme disease
- synovial fluid aspirate?
- serology?
- prognosis?
Bacterial culture of synovial fluid is usually negative in Lyme disease - diff to isolate
IgG serologies to B burgdorferi are positive in all patients with Lyme arthritis.
Lyme arthritis can be treated successfully with a 28-day course of oral doxycycline or amoxicillin. Prognosis is favorable, and most patients recover completely.
512
______ and _____ are the preferred antiarrhythmic agents to maintain sinus rhythm in patients with atrial fibrillation and left ventricular systolic dysfunction who failed rate-control strategy
Amiodarone and dofetilide
513
First screening test for Sarcoidosis, multisystem granulomatous disease.
- confirmed with?
Chest x-ray is often the first screening test as >90% of patients have bilateral hilar or mediastinal adenopathy.
excisional lymph node biopsy (noncaseating granulomas)
514
Methotrexate usage
ectopic pregnancy in hemodynamically stable patients.
RA (1st line)
515
ECG findings diagnostic of STEMI:
New ST elevation at the J point in >2 anatomically contiguous leads with the following threshold:
>1mm in all leads except V2 and V3
or
Women: >1.5 mm
- in leads V2 and V3
Men age >40 : >2 mm
Men age < 40 >2.5 mm
- in leads V2 and V3
New left bundle branch block with clinical presentation consistent with acute coronary syndrome
516
Patients with Down's syndrome are at a higher risk of developing ______ later in life.
acute leukemia
Alzheimer-like dementia
- NOT parkinson's
517
Metoclopramide is a central and peripheral D2-receptor blocker.
Its use can result in drug-induced extrapyramidal symptoms such as akathisia, dystonia, and parkinsonian-like symptoms in > __% incidence.
30%
| Metoclopramide has now been largely replaced by 5 HT3 serotonin receptor antagonists (e.g. ondansetron) and aprepitant.
518
Tx of BDZ withdrawal?
IV diazepam, if severe withdrawal (eg, markedly abnormal vital signs, delirium, seizures, psychosis). Life threatening.
Once withdrawal symptoms are controlled, the benzodiazepine should be tapered off gradually.
519
Patients with hydatidiform mole are at risk for ____________.
Management of hydatidiform mole is by ________, after which ______ levels are followed until they are undetectable for __ months.
gestational trophoblastic neoplasia
suction curettage
serial β-hCG
6
520
Why is risk of new-onset diabetes mellitus (DM) increased following renal transplant and highest within the first few months?
1. Immunosuppression medication adverse effects: Following renal transplant, patients are typically maintained on a multidrug regimen that can consist of glucocorticoids (eg, prednisone), calcineurin inhibitors (eg, tacrolimus, cyclosporine), and antimetabolic agents (eg, mycophenolate). Glucocorticoids cause weight gain and decreased insulin sensitivity, and calcineurin inhibitors cause reversible toxicity to pancreatic islet cells, leading to impaired insulin secretion.
2. Improved renal function: The healthy, transplanted kidney causes increased insulin excretion and is capable of increased gluconeogenesis.
521
Severe chronic obstructive pulmonary disease is commonly accompanied by _______, which is characterized by loss of lean muscle mass due to energy imbalance and systemic inflammation.
pulmonary cachexia syndrome
522
Once the diagnosis of NFI is suspected, ophthalmologic evaluation for __________ is indicated.
optic pathway gliomas
- Bilateral optic pathway gliomas are virtually pathognomonic for NFI but may be asymptomatic initially. Early detection is critical due to risk of progressive vision loss.
523
How to diagnose dermatomyositis?
clinical features and
serum antibody testing
- anti-Ro, anti-La, anti-Sm, anti-ribonucleoprotein (RNP), and anti-Jo-1 antibodies.
