Medicine 3 Flashcards
1
Q
Pt has Parkinsons: cogwheel rigidity, resting tremor, small writing, orthostasis, intact congnition.
He’s 55 yo, what is 1st line treatment?
Over 60?
A
Anticholinergics: benztropine or hydroxyzine
>60: Amantadine = increase dopamine release (too many SE with old people on anticholinergics)*
2
Q
Pt with severe parkinsons starting to have symptoms of pyschosis. Why is this? What should you do?
A
meds that increase dopamine can cause pyschosis.
Remove LEAST potent medications first, then reduce stronger meds.
Last start antipyschotic like quetiapine or clozapine
3
Q
Medications for parkinsons
Goal is to increase dopamine
A
- Anticholinergic if <60; benztropine/hydroxyzine
OR Amantidine >60 - Severe symptoms;
Levo or Cardiodopa (more efficacious, can see on-off phenomenon)
or
Dopamine antagonist (pramipexole, ropinerole, cabergoline)
Next
COMT inhibitors: tolcapone/entacapone to prevent metabolism of dopamine
MAO inhibitors: Selegiline or rasagiline
4
Q
Patients with primary, secondary or early latent syphyillis need what for tx?
A
x1 dose of IM Pen G
Primary: chancre w/ + RPR or VDRL confirmed with Darkfield or FTA
Secondary: rash/alopecia/conydlomata, dx with RPR or VDRL
Early latent = <12 months
*Start SSRI like sertraline for depressive symptoms
5
Q
What pts with syphillis need 3 weeks of IM penicillin?
A
Pt with Late lenent syphillis (no active symptoms with exposure >12 months ago)
Unknown duration of illness
Gummatous or CV syphillis
6
Q
Baby born with congenital syphillis, tx?
A
IV Pen G x 10 days
7
Q
PT comes in 2 weeks after hiking trip to Maine. Has a erythematous rash with pale center and target shaped on his shin, did have a tick bite.
Next step?
A
TREAT! you don’t have to confirm if high suspicion, tx with Doxycycline
For CNS involvement or cardiac: then CTX
Tx for joint/Bells palsy: doxy, amoxicillin or cefuroximine
8
Q
What are long term complications of Lymes disease?
A
JOint pain; common late manifestation
Cardiac: AV conduction block
Neuro: 7th CN palsy or Bells
Dx: IgM, IgG ELISA, Western blot or PCR
9
Q
Pt comes in with SOB with activity and headache. Recently traveled to Northwest on hiking trip, recalls a rash on leg with tick exposure. CBC shows anemia.
What further test do you want?
What co-morbidity makes this worse?
Tx?
A
C/f Babesiosis; transmitted by deer tick, get Hemolytic anemia
Get smear; shows tetrads of intraerythrocytic rings or can get PCR
Asplenic pt get more sick bc spleen removes damages RBC
TX: Azithromycin + atovaquone
10
Q
Pt comes in with rash, fever, HA. Had tick bite four days ago, Rash is maculopaular blanching over wrists and ankles. Dark spot at tick bite
How do you Dx?
Expected lab findings?
Tx
A
RMSP: rickettsia via tick peak in summer
Dx rickettsia serology or Bx
see LOW plts, LOW Na and elevated LFT
Tx: DOXYCYCLINE
11
Q
Side effects of Metformin
A
Works by blocking gluconeogenesis; no risk of hypoglycemia but DONT use if renal insufficiency.
diarrhea and lactic acidosis
12
Q
Side effects of Sulfonylureas (glyburide, glimepiride, glipizide) or Meglitinides (natelginide, repaglinide) used to tx T2DM
A
Act by increasing insulin secreation and blocks B-ell Katp channels
SE: Hypoglycemia (confusion), weight gain
13
Q
PT diagnosed with childhood absence seizures. Which medication should be started
What is seen on EEG
A
Ethosuximide
3 hz spike/wave discharges
Can see agranulocytosis; monitor CBC, but liver is fine
14
Q
What lab should you monitor when starting pt on valproic acid?
A
LFTs
15
Q
Boy comes in with mild BL flank pain. UA shows +2 protein, no blood, normal Na, BUN and Cr with normal BP,
Most likely dx, next step?
A
Probably orthostatic proteinuria
Get a 24hr UA; if elevated, get a split 24 hr collection; you can see if day vs night is higher, on feet with high protein diagnostic for orthostatic
IF proteinuria is persistent and NOT orthostatic, get renal Bx
16
Q
Good initial drug for Rheumatoid arthritis?
Failure of this drug… start this class
A
Methotrexate; folate antimetabolite; can cause hepatotoxicity and cytopenia
If fail, start Biologics such as TNF inhibitors
= adalimumab, etanercept, infliximab
17
Q
SE of TNF inhibitors (adalibumab, etanercept infliximab)
A
Infection, demyelination, CHF, malignancy
check interferon gamma release assay (TB reactivation can occur)
18
Q
Patient passed out and brought to ED, fine now. Felt lightheaded w/ pounding in chest prior to passing out
ECG with short PR interval, delta wave and wide QRS. Dx
Tx?
A
WPW–> lead to tachyarrythmia and atrial fibrillation
If pt is having symptomatic tachyarrtyhmia it’s automatic indication to tx with catheter ablation
19
Q
PT with HIV comes in, not taking HARRT therapy, CD4 count is 10. HA, n/v and lethargy with oral yeast infection. LP done:
increased protein, low glucose, very VERY elevated OP of 300 with low white count, lymphocytic predominance.
Dx
Tx?
A
Cryptococcal meningococcal encephalitis
seen in HIV when <50 or immunocompromised
Tx with Ampho and Flucytosine
will have LOTS Of head aches and elevated IP symptoms, tx serial LPs, steroids don’t help
Dont start ART therapy until 2-4 weeks in d/t immune reconstitution inflammatory syndrome
20
Q
Pt comes in for routine exam with 3/6 holosystolic murmur, with a palpable thrill at LUSB
Most likely cause?
A
VSD
21
Q
Pt with wide and fixed splitting of the second heart sound. Mid systolic ejection murmur.
A
ASD
22
Q
Pt comes in with three months of itchy and twitchy legs, worse when laying still, relieved by moving and pacing. No other PMHx, she is in her 50s with HTN controlled on amlodipine. Neuro and rest of PE normal.
Most likely dx?
Additional testing?
Tx?
A
dx restless leg syndrome
get iron stores or ferritin; can be associated with RLS
Tx pramipexerole (dopamine agonist) or gabapentin
23
Q
What affects does amiodarone have on thyroid?
A
decresease conversion of T3 to T4 so have higher T4
high iodine in amiodarone can inhibit thryoid hormone synthesis
Can induce thyroxicosis (will need tx w/ glucocorticoids)
24
Q
Pt in ED on cardiac monitor, is in afib and becomes unresponsive. No pulses present, not breathing. Next step?
A
Per ACLS… start Chest Compressions for pulseless electrical alternans
25
Pt in ED has palpitations and chest pain, monitor shows narrow complex tachycardia. He is alert. Next step?
SVT-- give IV adenosine
| IF unstable.. cardiovert!
26
When do patients undergo defibrillation?
ventricular tachycardia
| pulseless ventricular tachycardia
27
What are red flags for patient presenting with scoliosis?
dull or achy pain, pain that wakes at night
neurologic signs; paresthesias, B/B dysfunction
Rapidly progressing
Initially to spinal Xray
Gold standard is MRI
28
Pt comes in with chest pain and HTN with UDS + for cocaine. She is aggitated but CTAB, tachy but no murmurs.
Tx?
Benzos; will reduce sympathetic outflow to alleviate tachycardia and HTN
Next step is nitro for those symptoms
If refractory... you can use phenotolamine
DON"T use B-blockers; you get unopposed alpha 1 vasoconstriction
29
Pt is in 70s, having fluctuating memory issues; good days and bad days for past several months. Last year daughter felt her mom was more unsteady on her feet, she now takes very short steps and will find her dad talking to someone who isn't there on occasion.
On PE, rigid upper extremities
Dx?
Dementia with Lewy Body
Pt with reduced dopamine transporter uptake in basal ganglia on PET adn sleep study with REM w/o atonia.
preserved medial temporal lobe on CT or MRI
30
Pt is in 70s, having difficulty with memory and recall, loss of bladder control. Now has abnormal gait is very stiff.
Likely dx
Normal pressure hydrocephalus
31
Pt in 80s brought in with son, noticed his dad has been acting bizarre, he says whatever is on his mind and used to be a very conservative person so is surprised. What is most likely cause of dementia?
Frontotemporal dementia
32
In pt with newly diagnosed frontotemporal dementia, what medication do you need to be careful of 2/2 to side effects?
Often go on anti-parkinson drugs and anti psychotics.. they are EXTREMELY sensitive to anti-psychotics and can actually make confusion, Parkinsonism and autonomic dysfnx worse
33
One week old baby born at home comes to hospital, severely dehydrated, labs notable for low Na, elevated K. VItals notable for tachycardia and hypotension. On PE ambiguous genitals.
ML diagnosis?
Congenital adreanal hypoplasia
D/T 21- hydroxylase enZ deficiency
See hypoNa, hyperK, hypoT, hypoglycemia
ELEVATED 17-hydroxyprogesterone leads to elevated andgrogens and amb genitals; low cortisol, low aldosterone
34
What is the Tx for CAH due to 21-hydroxylase deficiency
Glucocorticoids, mineralocorticoids, high salt diet, genital reconstruction for girls, pyschotherapy
35
Pt presents to acute care, he has rapidly growing mass on anterior neck for past month, now difficulty swallowing. Has history of small goiter and family hx of hypothyroidism in several relatives. TSH is very elevated with low T3/4. +antithyroid peroxidase antiB.
ML diagnosis?
Thyroid lymphoma
Pts +antithryoid peroxidase and high TSH w/ low T3/4 suggestive of Hashimotos
This increases risk for thyroid lymphoma
36
____ is acceptable alternative to colonoscopy. When do you need to get colonscopy?
sigmoidoscopy
Need to visualize proximal colon if large >1.0 cm adenomatous polyp,l mult adenomatous polyps, villous or tubovillous morphology
37
Pt is teen, comes in with episode of witnessed GTC at home, now at baseline. Normal PE, labs and normal. Parents state he's has complained thepast few months he was jerking his arms more when he was falling asleep making it hard to sleep and was more anxious.
EEG with bilateral polyspike and slow waves
Dx and tx??
Juvenile myoclonic epilepsy
First line is valproic acid
can also have absence seizure
38
Side effects and required monitoring for valproic acid?
Get CBC; monitor for thrombocytopenia and other cell line depression
LFTS for hepatotoxicity and pancreatitis
Teratogenic; off while preggers
39
Screening 50yo M during routine exam, some weight loss over the past 6 months and constipation but otherwise no changes. Has 20 yr smoking hx, no drinking, no c/p.
Labs show elevated Ca level and otherwise WNL.
Next steps?
Order serum PTH
If elevated likely primary hyperparathydrisms
If not... higher suspicion for malignancy
Others: thyrotoxicosis,Vit A toxicity, immobilization, Vit D Toxicity, granulomatosis
40
Pt comes in with unknown ingestion. She is n/v, has dry mucous membraneson exam and is aggitated. Tachy with normotenisive BP, and tachypneic, astas are 98% on RA with temp of 100. pupils are 4+ and equally reactive.
Likely ingestion?
Salicylate
causes n/v and tachypnea w/ resiratory alkalosis and lactic acidosis as well as hypertherma with AMS all from stim of the medullary respiratory center and chemorectpor trigger zone
41
Lab abnormalties seen in patient with salicylate OD?
| Tx?
Mixed acid-base disorder;
primary respiratory alkalosis d/t activation of medullary respiratory center; see elevated pH with low PaCo2
AG metabolic acidosis due to inhibition of cellular metabolism (normal 8-14)
**Tx is sodium bicarb drip, supplemental glucose and monitor ABG
IF w/in 2 hrs ingestion.. activated charcoal
42
At what point do you screen for lung cancer in pt with smoking history?
Get low dose CT for pt btwn 55-80 who have a >30 pack year smoking history OR are current smokers or quit w/i last 15 years
43
What antiBx are indicated/safe in pregnancy for UTI?
```
Cephlexin
Amox-clavulanate
Nitrofurantion
NOT bactrim (NT defect 1st trimester)
NOT FlouroQ (cartiledge defects)
```
44
Lesions c/f melanoma should be ____
excised w/ 1-3mm margins
| Tx for BRAF mutations: Nivolumab or pembrolizumab
45
Tx for Bipolar; baseline
Depression
Mania
Lithium (goal 0.6 to 1.2 level)= mood stabalizer
Depressive symptoms; Add lamotrigine (can use as maintenance)
Mania: may need to add antipsychotic
46
Incidental pituitary adenoma discovered on CT when pt came in for head trauma. All hormone levels are normal and otherwise asymptomatic.
Recommended steps if
<5mm?
5-10mm?
Less then that, nothing
| 5-10 mm get yearly MRI for 2 years
47
_____ has a nonejection click followed by systolic murmur like MR; often occur in late systole as LV end diastolic volume increaes and may disappear in setting of large volume venous return
Mitral valve prolapse
48
A harsh holosystolic murmur at lower sternum increasing with inspiration
Tricuspid regurg
49
An ejection click followed by a crescendo-decrescendo systolic murmur that increases with increased venous return
Hypertrophic cardiomyopathy
50
Harsh holosystolic murmur with maximal intensity over left third and fourth intercostal space w/ palpable thrill
VSD
51
Sudden transient monocular blindness. Is reversible and sign of advanced CAD.
What other things do you see on PE?
Ischemia of central retinal artery = amaurosis fugax; see carotid bruit on doppler
52
Old woman comes to office, vaginal pruitis, dysuria, incomplete voiding and noctururia. On exam see atrophic vagina, the labia minora look fused and there's erosions over the clitoris to labia majora and perineum. UA normal
Dx
Tx
Vulvar lichen sclerosus; in prepubertal and postmenopausal women
Tx: coticosteroid ointment and get punch Bx to r/o malignancy
53
Pt presents with months of increased tiredness, abdominal distension and fullness after meals. Feels down but not having SI or other depressive symptoms. Labs notable for macrocytic anemia, normal plts and WBC, LOW serum cobalamin and normal folate level.
LIkely Dx?
Next step for management?
Perniscous anemia in setting of Vit B 12 or cobalamin defieincy (low while folate normal)
Get Serum auto-antiB agains intrinsic factor
Absent rugae in stomach; glandular atrophy, intestinal metaplasia and inflammation.
*High Yield*
54
Pt with UC comes in with flare. Exam notable for distended and typmapnic abdomen, tachy and mild hypotension with dehydration.Labs notable for elevated WBC and PLTS, otherwise WNL. Stool studies negative.
Initial imaging?
Tx?
Abdominal XRay; sounds like toxic megacolon
Will need bowel rest, +/- antiBx and start Steroids
do NOT use 5 ASA (sulfasalamine) in pt in active flare/toxic megacolon
55
Difference on PE btwn epididymitis vs torsion
relief of pain with elevation in epididymitis, not in torsion, also lack reflex
56
Multisystem disease; pt presents with new onset facial palsy, months of joint pain and low energy. Mild hepatomegaly on exam and diffuse lymphadenopathy. No fever or rashes, no VS abnormalities
What image would you get?
What do you suspect?
CXR
sarcoidosis; joints, lymphadenopathy, hepatomegaly, uveitis, can get erythema nodosum and on CXR see hilar or mediastinal adenopathy
57
Tx for PMS or PMDD?
SSRI; still symptoms try a different SSRI
OR
OCP (estrogen + progesterone) if open to it
58
TTP and ITP can be tricky to tell apart.
How are they the same?
Different?
ITP: antiB agaist plt antigens, see thrombocytopenia, bruising and petichae but NOT micorangiopathic hemolytic anemia
TTP has MAHA (shistocytes on smear)
59
Tx for ITP
Suppresion of antibodies against platelet antigens
60
Tx for TTP
Plasma exchange; increase amount and activity of plasma metalloprotease
May need steroids or rituximab
low ADAM13 results in uncleaved vWF multimers leads to plt trapping and activation (acquired or hereditary)
61
Pt presents from Africa, pain with peeing, blood in urine at end of stream and increased frequency. Labs notable for anemia with low MCV, eosinophilia.
likely dx?
Schistomsomiasis; parasite seen in sub saharan africa
causes dysuria, increased frequency, terminal hematuria and peripheral eosinophilia.
Dx with urine sediment shows parasite eggs
62
Pt with symptoms of poor growth, mild fatigue. From south east asia UTD on shots .
CBC with anemia, MCV of 68, mean corpuscaular hemoglobin low with increased RBC number and high normal RDW. Ferritin slightly elevated
Dx
Thalassemia; alpha minor
mild microcytic, hypochromic anemia
low MCV = microcytic
low mean corpuscular hemoglobin= hypochromic
elevated ferritin 2/2 to increased RBC turnover
seen in sub saharan african, mediteranean, southeast asian, middle eastern
63
how long do pts with mechanical valves need to be on anticoag?
need to be on ASA and warfarin for life with goal INR of 2-3 if no RF are present
2.5 to 3.5 IF;
mitral vavle replacement
aortic valve replacement + RF
in the first 3 months after AV replacement
64
When do old people need to be hospitalied for PNA and what tx are they started on?
CURB-65 >2 score (confusion or lethargy, urea over 20, RR >30, BP <90 or <60, age >65
Tx with anti-pneumococcal beta-lact (CTX) and advanced macrolide (azithro or flouroquinolonges)
65
Recommended management for pt with inferior wall MI (ST elevation in II, III and aVF) with bradycardia and hypotension
Tx with IV atropine (anticholingeric)
| The SA node blood supply likely down thus increases vagal tone
66
All pts with newly diagnosed medullary thyroid carcinoma require these additional tests due to concern for this diseae
Plasma free metanephrines (for pheochromocytoma) and calcitonin (for hyperPTH d/t PTH adenoma/hyperplasia)
MEN2A; RET protoncogene
67
PT is getting a carotid endarterectomy, inadvertent transection of this nerve results in tongue deviation to the side of the injury.
hypoglossal nerve
68
What is the recommended tx for active variceal bleed in pt that is unstable? Including medication
What do we do to prevent re-bleed
Intubate, start octreotide and then scope
Band or clip
Start non-selective beta blocker for prevention
69
PT comes in with weight loss, abdominal cramping adn has not had her menses in four months. Feels weak with decreaesed appetite. Not sexually active (20 yo). On PE she has sparse axillary and pubic hair, hyperperigment skin.
Likely dx?
What is likely present on labs?
Addisons; adrenal insufficiency
hyponatremia, hyperK adn mild hyperchloremic metabolic acidosis and mild hypoglycemia
Get morning cortisol level + ACTH: low cortisol + elevated ACTH = adrenal insuff
70
Pts with of 2 or more the following symptoms + GERD
| white, male >50, hiatal hernia, obese, smoking hx need what?
```
scope + bx to screen for baretts
If columnar line esophagus + metaplasia
--no dysplasia= PPI repeat in 3-5 yr
--low grade = PPI + scope in 6-12 mo
--high grade = endoscopic eradication
```
71
what physicians do to act in benefit and for patients even in situations w/o consent
beneficience
72
Male coming in with three months of low back pain, worse in morning, better after wakes up and moves around and exercises. Limited ROM on forward flexion as LS spine and slightly diminished chest expansion.
Imaging?
Likely Dx?
Xray of SI joint: check AP and lateral view of L spine, Lateral view of C spine, pelvic radiograph for SI and jip
likely ankylosing spondylitis; see sacroilitis
**HLA B27 frequently present (but also in other spondyloarthropathies)
73
Tx recommendation for ankylosing Spondylitis
```
NSAIDS
biologics: infliximab or adalimumab
Sulfasalazine
IL 17 antagonist
NOT steroids
```
74
What are additional manifestations of AS?
actue anterior uveitis or cataracts, aortic regurg and mitral valve prolapase, apical pulmonary fibrosis and restrictive lung disease, IgA nephropathy
75
16yoF comes to ED with left knee pain after landing on it during basketball game. Pain is severe, swelling on anterior portion and pt cannot extend the knee or maintain passive extension of knee. Neg ant drawer test, McCurry negative and no laxity or valgus or varus.
Dx
Patellar tendo tear
| Needs surgery!
76
See this in pts that have been outdoors, have papule at site of scrape/inoculation and eventually ulcerates and drains a clear odorless fluid. Can progress into more lesions and now lymphatic chain enlargement near by.
Sporotrichosis; fungal from sporothrix
Tx: oral itraconazole
Dx with culture
77
Pt with 6 mo of large volume loose stool, increased gas, a 10 lb wt loss in the past 6 months. Labs notable for microcytic anemia and Fe deficiency. No elevation is ESR, no blood in stool. Stool study notable for elevated osmotic gap (watery). Likely Dx?
Celiac
| See villous atrophy with increased intraepithelial lymphocytes and crypt hyperplasia
78
Pt has newly diagnosed femoral hernia. What is tx?
Surgical repair
79
Who gets intrapartum prophylaxis?
```
GBS + after 35 weeks (culture)
Unknown GBS status;
-preterm <37 wks
-ROM >18 hrs at any GA
-Intrapartum fever
ANY GBS bactiuria during this pregnancy or prior baby with EOS GBS
```
80
Tx recommendation for ankylosing Spondylitis
```
NSAIDS
biologics: infliximab or adalimumab
Sulfasalazine
IL 17 antagonist
NOT steroids
```
81
What are additional manifestations of AS?
actue anterior uveitis, aortic regurg, apical pulmonary fibrosis and restrictive lung disease, IgA nephropathy
82
Pt comes in with rabies exposure, you need to give prophylaxsis; no prior hx of receiving this tx and no prior exposure. Tx?
What if that same pt had received the rabies post exposure prophylaxsis last year?
Rabies vaccine + rabies immunoglobulin
If prior vaccines; then they just need vaccine again, NO rabies immunoglobulin
83
Pt was playing soccer and got tackled from the right side, had a direct blow to the knee. No ant drawer or Lachman sign. There is laxity with valgus stress and ttp on medial joint line
MCL sprain
84
Pts with T1 or 2DM should be started on statin when they are =/> _____ years old or if LDL is > ____
40
| LDL > 70
85
Who gets intrapartum prophylaxis?
```
GBS + after 35 weeks (culture)
Unknown GBS status;
-preterm <37 wks
-ROM >18 hrs at any GA
-Intrapartum fever
ANY GBS bactiuria during this pregnancy or prior baby with EOS GBS
```
86
What is first line tx for Cdiff?
First recurrance?
Mult recurrance?
Vanc or fidaxomicin
1st recurrance: Vanc for longer course
Multiple: Vanc + Rifaximin or fecal transplant
87
Medications that cause BL galactorrhea
Haloperidol
Rsperidone
Metoclopramide
SSRI
88
Pt comes in with rabies exposure, you need to give prophylaxsis; no prior hx of receiving this tx and no prior exposure. Tx?
What if that same pt had received the rabies post exposure prophylaxsis last year?
Rabies vaccine + rabies immunoglobulin
If prior vaccines; then they just need vaccine again, NO rabies immunoglobulin
89
Goal INR for warfarin 2-3; management when more?
<5
5-9
>9
<5 hold a dose, retest adn decrease dose
5-9: hold warfirn and restart when therapeutic; can admit low dose oral vit K IF increased bleeding risk
>9: hold warfarin, give high dose oral vit K
90
Pts with T1 or 2DM should be started on statin when they are =/> _____ years old or if LDL is > ____
40
| LDL > 70
91
Pt presenting with joint pain, purpuric skin lesions, hx of IV drug use (or Hep C infection) and renal involvement are highly suspicious for...
Dx?
Tx?
Cyroglobulinemia
Get serum cryoglobulin component leveles; pt with have low complement, most accurate is Bx
Tx initially with immunosupprive therpy.. long term tx hep C; boceprivir/telprevir/simeprevir/sofosbuvir
92
How is graves managed during pregnancy?
PTU for first trimester (Methimazole = birth defects)
| Methimazole for 2nd and 3rd (PTU = liver failure risk)
93
Most common fracture of upper extremity; often happens after landing on outstretched hand, swelling on dorsum with mild dorsal angulation at wrist joint
Distal radial or Colles fracture
94
Pt with aids has low grade fever, hepatosplenomegaly adn rash over body; papules with central ubmilication with small areas of central hemorrhage and some with necrosis. ML diagnosis?
```
Cutaneous cryptococcosis (seen with CD4 <100)
dx with biopsy and histo staining; see encapsulated yeast
```
95
Pt presents with thoracic back pain, wraps around back, weakness in LE and decreased sensation in the legs with numbness. Has brisk LE reflexes and diminished strength. Recently tx for non-hodkins with chemo/radiation
Likely Dx?
Next steps?
spinal cord compression
| medical emergency; IV steroids to reduce edema and imaging with MRI; may need surgery
96
Pt in 50s with proximal muscles weakness (difficulty climbing stairs) tender to palpation in joints with elevated Ck on exam and mild elevation in AST
Dx?
POlymyositis
+ for anti-Jo and ANA
Tx: steroids and may need MTX or ASA but MUST watch for pulm complications... get PFTs to distinguish from ILD
97
Pt with T2DM well controlled has rash on arm; itchy and painful with now central clearing. Diarrhea, facial flushing and weight loss. Doesn't feel herself. Dx
Glucagonoma
| pancreatic tumor associated w/ mild DM and classic rash
98
infant with constipaiton, oculobulbar weakness, descending flaccid paralysis (previously healthy infant) lives on farm
Botulism; flaccidneuropathy
| seen in honey or dust; neurotoxin that inhibits presynaptic acetylcholine release in the NMJ
99
A previously healthy 1 year old with loss of motor milestones, decreased tone in LE, tongue fasciulations on exam. Diminished reflexes on exam
SMA
| degeneration of anterior horn cells
100
Pt with aids has low grade fever, hepatosplenomegaly adn rash over body; papules with central ubmilication with small areas of central hemorrhage and some with necrosis. ML diagnosis?
```
Cutaneous cryptococcosis (seen with CD4 <100)
dx with biopsy and histo staining; see encapsulated yeast
```
101
PT with smoking hx and lesion in right upper lobe on xray has right shoulder pain, hand and muscle atrophy on the right side and pupil size asymmetry. Concerning for what type of tumor?
What is concern if you see asymmetry in reflexes in LE?
Pancoast tumor in the superior pulmonary sulcus
| C/F invasion and spread of tumor to the spinal cord leading to compression
102
Pt in 50s with proximal muscles weakness (difficulty climbing stairs) tender to palpation in joints with elevated Ck on exam and mild elevation in AST
Dx?
POlymyositis
+ for anti-Jo and ANA
Tx: steroids and may need MTX or ASA but MUST watch for pulm complications... get PFTs to distinguish from ILD
103
first line management for all prolactinomas; both small and large, that causes elevated prolactin and symptoms.
Women; amenorrhea and low estradiol levels and mass effect
Men: ED and mass effect (of the optic chaism)
Tx: oral dopaminergic receptor agonist (cabergoline or bronmocriptime)
104
Pt w/ unilateral HA, repetitive. gets eye watering and runny nose, better with going into a dark room. Pitosis and misosis also present in acute HA.
Type of HA
Best preventative
abortive?
Cluster
Verapamil for prevention
Abort with oxygen or triptans (can do inhtranasal to contralateral nare) but try not to overuse
105
Causes right heart failure; see peripheral edema, ascites, elevated JVD with hepatojugular reflux, Kussmaul sign, pericardial knock and pericardial calcifications on CXR
Constrictive pericarditis
| Often see pericarditis as complication of CABG
106
best initial treatment for insomnia?
CBT
Then can add in medications or hypnotics but very careful in elderly given adverse SE; no benzos, no anticholinergics if BPH
107
What does it mean when the Anti-HBc total is the only positive on Hep B panel?
Next step?
Acute infection; window period...
REPEAT serology for false positive; then get IgM anti-HBc (recent) as well as LFTs (elevated = acute)
OR may indicate years after recovery from acute HBV once the anti-HBs waned off (nml LFTs and IgM anti-HBc is usually negative)
OR; may indicate years of chronic infection which the HBsAg has fallen to undetectable level (may have chronic liver dx)
high yield
108
Pt with frisky sexual hx comes to clinic with diffuse maculopapular rash including palms and soles, painful ulcer in mouth, diffuse lymphadenopathy with fevers and malaise and HA.
CBC with leukopenia and thrombocytopenia
Dx
acute retroviral syndrome from HIV
| seems like secondary syphillis but ulcers are usually painless
109
Contraindications to fibronolysis to tPA in setting of ischemic stroke
active internal bleed or BLEEDING RISK
bleeding diathesis of PLT <100,000
hypodentsity in >33% of an arterial territory on CT or incracranial hemorrhage
BP >185/110
110
After a stroke is dx and tx with tPA; need to determine cause; which studies are performed?
CT angio of the carotids and incranial vasculature, duplex US
ECG for MI or arrhythmia as cause
Echo for intracardiac thrombus
111
Best antihypertensive medication for pts with gout
Losartan; angiotensin receptor blocker
| Ca channel blockers and furosemide can decrease excretion of urate; avoid
112
Pt on lithium, starts having symptoms of decreased energy, sluggish and fatigue.
Lithium level normal TSH is elevated with low T4.
Next step?
Tx?
Lithium interferes w/ synthesis and release of thyroid hormone; see goiter or hyoT;
CONTINUE the lithium if pt needs it and tx with LEVOTHYROXINE
113
First line therapy in patients with dementia related cognitive impairment
Acetylcholinesterase inhibitors: Rivastigmine, donepezil or galantamine; increase cholingertic transmission
OR Memantine; NMDA receptor antagonist
114
Pt in 30s comes in with progressive dypsnea and fatigue with cough and malaise.
CXR shows bilateral hilar lyphadenopathy
Has reduced diffusion capacity for CO and obstructive picture on spirometry; reduced FEV1
labs notalbe for elevated ESR and Ca
Dx?
Test to dx?
Tx?
Sarcoidosis; seen in healthy young adults; systemic inflammatory dx
Dx with bronchoscopy and biopsy
Tx: orgal steroids for 12-24 months and most resolve
115
Tx for Acute coronary artery syndrome?
Dual antiplatelte therapy (ASA and P2Y12 receptor blockers... clopidogrel, prasurgrel or ticagrelor)
Nitrates
Bblcokers
Statins
Anticoag (heparin, LMWH, bivalirudin, fondaparinux)
if STEMI get to cath lab
116
Pts that have received 3 or more tetanus toxid doses a booster is ONLY indicated if....
its been >10 yrs since booster (minor wounds)
| its been>5 ys for severe or dirty wounds
117
Pts who have received less than ____ tetanus dosese or who vaccine status is uncertain should get booster
IF wound is severe and dirty should also get?
3
| get tetanus immunoglobulin
118
Best way to diagnose ACTIVE TB in pt with highly suspicious history and concerning CXR?
Get SPUTUM sampling x3 at 8 to 24 hr intervals and send for acid fast bacillus smear (low sensitivity) and myco culture as well as NAA testing (MUCH more sensitive)
Can also do TB skin test or interferon gamma HOWEVER these do not distinguish btwn active and latent TB
119
What affect does pregnancy initally have on TSH and T3/4?
b-hcg binds TSH receptors (thus thyroid follicular cells stimulate thyroid production--> increase T3 and 4 production
Elevated estrogen increases TBG leading to increased T3/4
Thyroid requirements increase by 25-50% during pregnancy
120
Pt is 5 wks pregnant,on levothyroxine for hashimotos. How do we manage thyroid hormone?
increase levothyroxine empirically by 30% when pregnancy is detected and then measure 4 weeks later; adjust based on trimester-specific norms
121
The most common cause of cellulitis?
GAS or strep pyogenes; use cephalexin for about 5 days for outpatient
122
MCC of hemoptysis?
| What is treatment for this?
Acute bronchitis
| trial of antiBx in pt with dypsnea, increased sputum production and increased sputum purulence
123
First line tx for breast feeding PPD?
sertraline or paroxetine
124
injuries to _____ seen in soccer/basketball/tennis with rapid direction change/pivot or contact sports. 'Popping' sensation, rapid onset hemarthorsis, joint instability and inability to bear weight.
ACL
| +Lachman or anterior drawer
125
Pt is 5yo, its summer, comes in with sore throat, fever and decreased PO. No lymphadenopathy, there are vesicles and ulcers on the posterior oropharnynx
herpangina
126
Pt comes in with LE weakness, some difficulty walking. Previously healthy, did have URI last week but neg sexual hx, no drug use. Now having urinary retention and altered sensation in the LE. PE noteable for hyporeflexia at knees and ankles
Transverse myelitis
