Medicine GI, CV, Fem/M-Rep, Heme Onc, Pulm, Ren, NS

Question 1

Pt with recurrent episodes of pneumonia, sinusitis, and GI infections should make you think of? What test should you get to establish the diagnosis?

Answer 1

humoral immunity defect -> get serum Ig to establish a diagnosis

Question 2

renal vein thrombosis is commonly associated with which nephrotic syndrome?

how does it present?

Answer 2

membranous glomerulopathy

presents with typical nephrotic syndrome features caused by hypoalbuminemia: periorbital edema, abdominal disteinsion/ascites, lower extremity edema, proteinuria

renal vein thrombosis: acute onset of abdominal pain, fever, and hematuria

Question 3

2 major side effects of statins

Answer 3

rhabdomyolysis, can lead to renal failure

slightly elevated transminases

Question 4

most rapid way to decrease serum K concentration (2)

Answer 4

insulin (effect usually occurs within 15-30min) + glucose to avoid hypoglycemia

K can be shifted intracellularly more quickly than it can be removed from the body. However, because this effect is transient, efforts to decrease the total body K should still be made via

Kayexalate (1-2hrs)

furosemide

ß2 agonist

Question 5

Rx that have been shown to confer a survival benefit in CHF

Answer 5

ACEi

ARB

ß-blockers

spironolactone

“SAAB”

Question 6

most common cause of CKD and ESRD requiring dialysis

Answer 6

diabetes

Question 7

why and when does diabetic nephropathy usually occur?

what other symptoms do patients usually present with?

Answer 7

10-15 years after the onset of type I/II DM

occurs because advanced glycation end products and other inflammatory mediators damage the glomerulus, resulting in proteinuria, glomerular nephropathy, and ESRD

at this point, patients typically have 3+ protein, elevated creatinine, decreased visual acuity, elevated BP, and no active urinary sediment (red/cellular casts) to indicate a different etiology of the proteinuria

Question 8

What is the PVR in a patient with significant bladder outlet obstruction (ie BPH)?

Answer 8

>50 cc

Question 9

2 coronary vasodilators

Answer 9

dipyridamole and adenosine

Question 10

what is the coronary steal phenomenon? What medications are usually employed to test this and what is it used to test for?

Answer 10

dipyridamole & adenosine - coronary vasodilators

CPS - in patients with CAD, the diseased vessels distal to the obstruction are maximally dilated (ie their ability to increase myocardial perfusion is limited). Thus as the non-diseased vessels are dilated by these medications, there is a redistribution of coronary blood flow to non-diseased areas, resulting in diminished perfusion of the diseased segments

used to diagnose ischemic heart disease

Question 11

Patient w/ UC presents with 6 mo history of fatigue and pruritis.

Albumin 3.8

Tbili 1.7 (slightly elevated)

Alk Phos 816 (elevated)

AST 45 (WNL)

ALT 54 (WNL)

ESR 102 (high)

pANCA (+)

What is your leading diagnosis? How would you confirm it?

Other common presenting symptoms?

Answer 11

Primary sclerosing cholangitis

diagnose with cholangiogram (ERCP or MRCP) - shows multi-focal narrowing with intra-hepatic and extra-hepatic duct dilation

other symptoms are releated to cholestasis - fatigue, pruritis, steatorrhea, fat soluble vitamin deficiencies, metabolic bone disease, hepatic failure

Question 12

metabolic and electrolyte changes in a patient with bulimia nervosa

treatment and justification of treatment?

Answer 12

chronic vomiting -> volume depletion + HCl loss ->

metabolic alkalosis

hypoklaemia

hypochloremia

trmt: normal saline - restores arterial volume, correct hypochloremia, and increases urinary bicarb excretion

^{note that metabolic acidosis consists of 2 phases: generation phase (excess bicarb produced) + maintenance phase (process preventing renal bicarb excretion)}

• ^{generation phase - due to urinary or GI H+ losses (diuretics, vomiting) or decreased PO intake}
• ^{maintenance phase - due to hypovolemia, kidneys perceive decreased effective circulating volume and results in RAAS activation -> reabsorption of Na, K, excretion of H, decreased excretion of bicarb}

Question 13

physiology of metabolic acidosis secondary to an underlying disorder

treatment?

Answer 13

consists of 2 phases: generation phase (excess bicarb produced) + maintenance phase (process preventing renal bicarb excretion)

generation phase - due to urinary or GI H+ losses (diuretics, vomiting) or decreased PO intake

maintenance phase - due to hypovolemia, kidneys perceive decreased effective circulating volume and results in RAAS activation -> reabsorption of Na, K, excretion of H, decreased excretion of bicarb

trmt: normal saline to restore arterial volume, correct hypochloremia, and increases urinary bicarb excretion

Question 14

rapid association: systolic-diastolic abdominal bruit in a patient with HTN and atherosclerotic disease

Answer 14

renal artery stenosis

Question 15

rapid association: patient with history of HTN has a medication list that includes lisinopril, HCTZ, amlodipine, metoprolol, aspirin, metformin, and glyburide; current BP is 190/120

Answer 15

renal artery stenosis - note that his BP is still high despite the use of multiple medications

Question 16

What is SAAG?

What are the implications of this value?

Answer 16

serum-to-ascites albumin gradient

^{(calculate by substracting peritoneal fluid albumin conc. from serum albumin conc.)}

used to assess ascitic fluid to diagnose the etiology

SAAG > 1.1 = portal HTN/cardiac ascites/increased hydrostatic pressures within hepatic capillary beds

SAAG < 1.1 = other etiologies (malignancy, pancreatitis, nephrotic syndrome, tb)

Question 17

pt presents with fatigue, dark urine; PE shows icteric sclera and skin. Labs shows elevated AlkPhos.

Next best step in management?

Answer 17

get US

elevated alkphos are indicative of cholestasis and these patients should be elevated with an RUQ US to assess for intra- vs extra- hepatic causes of biliary obstruction

(+) biliary dilation -> extrahepatic cholestasis

(-) biliary dilation -> intrahepatic cholestasis

Question 18

when a patient presents with weight loss, blood in stools, and has a family history of colon cancer, aside from the w/o for colon cancer, what else should the patient be evaluated for?

Answer 18

endometrial cancers.

Why? She has Lynch syndrome (aka HNPCC), and Lynch II is associated with a high risk of extracolonic tumors, the most common of which is endometrial carcinoma, which develops in 43% of females in affected families

Question 19

Best imaging modality for assessing patients with an acute episode of diverticulitis

Answer 19

CT scan

However, if you suspect a perforation secondary to diverticulitis, an upright xray may be employed to look for free air under the diaphragm

AVOID colonoscop/sigmoidoscopy during an acute episode, as the endoscope can perforate the fragile bowel and lead to massive contamination of the abdominal cavity with fecal material

Question 20

3 major cardiac causes of arterial emboli

Answer 20

LV thrombus, usually secondary to recent STEMi

atrial thrombus secondary to a-fib

aortic atherosclerosis

Question 21

most common complication of PUD and how does it present?

Answer 21

hemorrhage - presents as hematemesis +/- melena, though a massive upper Gi bleed may present as hematochezia (usually a sign of lower GI bleed)

other complications: perforation, penetration, obstruction

Question 22

pre-test probability of coronary artery disease is based on several factors. What dictates a low-risk patient?

These patients typically undergo a stress test, which can be positive or negative. How would you interpret either one?

Answer 22

low-risk: men <40/women <50 with atypical chest pain and ø significant cardiac risk factors (non-smoker, no family hx of premature CAD)

(+) stress test in patients at low-risk for CAD -> likely to be a faslse (+)

(-) stress test in patients at high-risk for CAD -> likely to be a faslse (-)

Question 23

Hep C is a risk factor for these diseases

Answer 23

cirrhosis

HCC

cryoglobulinemia

glomerulonephritis

Question 24

What is a parapneumonic effusion and what are they typically caused by?

What are the different types and how are they managed?

Answer 24

type of pleural effusion that arises as a result of apneumonia, lung abscess, or bronchiectasis; can be either

• uncomplicated - exudative (predominately PMNs) effusions secondary to inflammation associated with pneumonia; gram stain is negative for any organisms; resolve with abx
• complicated - bacterial invasion into the pleural space, leading to incr. # of PMNs, decr. glucose levels, pleural fluid acidosis, and elevated LDH; (ie if there is pus, (+) gram stain of pleural fluid, or pH <7.0); resolves with drainage via chest tube
• empyema - accumulation of pus in pleural space; resolves with abx + drainage

Question 25

rapid association: pleural fluid has a pH of 7.3 management?

Answer 25

empyema diagnose with CT; removal of fluid by thoracostomy

Question 26

rapid association: pleural fluid has a glucose of 59 management?

Answer 26

empyema ^{(anything <60 is indicative of empyema)} diagnose with CT; removal of fluid by thoracostomy

Question 27

indications for tube thoracostomy

Answer 27

pH \< 7.2 glucose \< 60

Question 28

T/F digital clubbing is a feature of COPD

Answer 28

False - it is not a feature of COPD, but is actually suggestive of another etiology (lung Ca, cystic fibrosis)

Question 29

What is ARDs?

Answer 29

acute hypoxemic respiratory failure characterized by diffuse alveolar damage with pulmonary edema that is **not** due to heart failure or volume overload patients develop **severe respiratory distress** and **severe hypoxemia, where the ratio of arterial O₂ tension (PaO₂) to FiO₂ is \< 300**

Question 30

What is the FEV1/FVC ratio, VC, and DLCO seen in restrictive lung disease?

Answer 30

FEV1/FVC ratio = normal - increased VC = low DLCO = decreased

Question 31

What is the etiology of Zenker's diverticulum? Where does it usually develop? What is the standard treatment?

Answer 31

upper esophageal sphincter dysfunction + dysmotility usually develops above the upper esophageal sphincter with posterior herniation btwn the fibers of the cricopharyngeal muscle trmt: excision and cricopharyngeal myotomy

Question 32

INR goal of patient with prosthetic heart valves

Answer 32

2.5 - 3.5

Question 33

INR goal of patient with idiopathic DVT

Answer 33

2.0 - 3.0

Question 34

4 features of nephrotic syndrome common complication?

Answer 34

proteinuria \>3-3.5 g/day hypoalbuminemia edema hyperlipidemia and lipiduria _common complication_: **hypercoaguability** with risk of venous + arterial thrombosis (commonly ***renal vein thrombosis***, which is most common with membranous glomerulopathy) ^{Usually due to urinary loss of antithrombin 3, protein C/S, increased platelet aggregation, hyperfibrinogenemia due to increased hepatic synthesis, and impaired fibrinolysis} _other complications_: protein malnutrition, iron-resistant microcytic hypochromic anemia, increased susceptibility to infection, vitamin D deficiency

Question 35

patient with history of asthma on inhaled albuterol, steroids, salmeterol, and cromolyn. She is admitted and given nebulized albuterol, IV steroids, and o2. What do you expect her CBC to look like?

Answer 35

elevated WBC with leukocytosis (PMN predominance) steroids increase the PMN count by stimulating bone marrow release and mobolizing the marginated neutrophil pool

Question 36

∆ btwn hypertensive urgency vs emergency?

Answer 36

* **urgency** - severe HTN w/o symptoms or evidence of end-organ damage * **emergency** - markedly severe HTN associated with malignant HTN or hypertensive encephalopathy * **malignant** - long-standing, uncontrolled HTN associated with retinal hemorrhages, exudates, or papilledema; can lead to malignant nephrosclerosis (ARF, hematuria, proteinuria) * **encephalopathy** - cerebral edema due to breakthrough vasodilation from failure of autoregulation, results in an insidious onset of HA, N, V followed by non-localizing neurologic sx (restlessness, confusion, seizures/coma) if untreated, can also develop SAH or ICH severe HTN: ¨≥¨180/120 mmHg

Question 37

Hypertensive emergency has two subtypes - what are they and what are the defining features?

Answer 37

* **emergency** - markedly severe HTN associated with malignant HTN or hypertensive encephalopathy * **malignant** - associated with retinal hemorrhages, exudates, or papilledema; can lead to malignant nephrosclerosis (ARF, hematuria, proteinuria); usually seen in patients with long-standing uncontrolled HTN * **encephalopathy** - cerebral edema due to breakthrough vasodilation from failure of autoregulation, results in an insidious onset of HA, N, V followed by non-localizing neurologic sx (restlessness, confusion, seizures/coma) if untreated, can also develop SAH or ICH severe HTN: ¨≥¨180/120 mmHg

Question 38

Hematuria can be of two etiologies - what are they, what are common causes of each, and what does the UA normally show?

Answer 38

non-glomerular * gross hematuria * etiology: cancer, infections, PCKD, nephrolithiasis * UA: **RBC w/o proteinuria** * sx: dysuria, flank pain, renal colic depending on etiology glomerular * microscopic hematuria (gross may be present in some) * etiology: glomerulonephritis or basement membrane disease * UA: **dysmorphic RBCs, RBC casts, _with_ proteinuria** * sx: absent or non-specfiic (low back pain), but commonly has features of nephritic syndrome (hematuria, HTN, oliguria, elevated Cr)

Question 39

Treatment for patients with dyspnea, orthopnea, PND, bibasilar crackles, hypoxemia

Answer 39

think: **pulmonary edema, most likely due to acute decompensated heart failure** (which is commonly due to LV systolic or diastolic dysfunction) mgmt: IV furosemide + supplemental O2

Question 40

patient presents with long-standing heartburn, significant weight loss, fatigue, and smoking history next step in management?

Answer 40

think: likely to be esophageal cancer start with: barium swallow followed by endoscopy; if negative, proceed to CT of chest +/- contrast

Question 41

management of esophageal cancers

Answer 41

if localized: surgery +/- preop chemo/radioTx; curative if metastatic: palliative thearpy (ie chemo/radioTx); not curative

Question 42

How to diagnose toxic megacolon? how are these patients managed?

Answer 42

**plain abdominal x-rays** ^{dilated R or transverse colon (>6 cm), possible air-fluid levels, thick haustral markings that
do not extend across the entire lumen} ≥3 of the following: **fever \>38 C (100.4)** **pulse \>120/min** **WBC \>10.5** **anemia** conservative mgmt: **IV F, steroids, broad spectrum abx, bowel rest** **subtotal colectomy with end ileostomy** if colitis does not resolve medical emergency b/c it can lead to colonic perforation

Question 43

how do patients with UC develop toxic megacolon?

Answer 43

UC patients typically have inflammation limited to the colonic mucosa, but sometimes the inflammation can extend to the smooth muscle layer, leading to muscle paralysis and colonic dilation

Question 44

CMV colitis usually affects which patient population

Answer 44

HIV+

Question 45

How do R vs L sided colon cancers tend to present?

Answer 45

both associated with ∆ bowel habits R sided - anemia, FOBT+ L sided - bowel obstruction, constipation, abdominal pain

Question 46

25 yo M smoker recently diagnosed with UC

Answer 46

**annual colonoscopy with biopsies** once the disease has been present for at least 8 years (even if the disease is relatively well controlled with medications); **total colectomy** if dysplasia is detected UC has an increased risk of colorectal cancers, which is proportional to the duration and extent of the disease

Question 47

rapid association: WBC casts

Answer 47

tubulointerstitial nephritis usually drug induced (NSAIDs, diuretics, penicillin derivatives, sulfonamides, rifampin)

Question 48

most common paroxysmal tachycardia in people without structural heart disease how is this usually managed?

Answer 48

paroxysmal supraventricular tachycardia (PSVT) - attacks begin abruptly and are characterized by HR in 160-220s; caused accessory conduction pathways that allow re-entry through the AV node mgmt: **vagal maneuvers** (valsalva, carotid massage, immersion of face in cold water) increase vagal tone and decrease conduction through the AV node, which can slow the HR and often break the rhythm _or_ **adenosine**

Question 49

characteristic levels of AST/ALT in patients with alcoholic hepatitis

Answer 49

AST : ALT \> 2, with absolute values **\< 500 IU/L**

Question 50

major ADR of metformin (2)

Answer 50

lactic acidosis + sepsis

Question 51

management of patient with hypernatremia

Answer 51

remember that it reflects a water deficit and usually occurs in patients who are debilitated or have altered mental status and cannot have access to free water. mild cases: D5W 1/2NS severe cases: 0.9% NS

Question 52

FEV1/FVC \<70% with low DLCO

Answer 52

emphysema

Question 53

FEV1/FVC \<70% with normal DCLO

Answer 53

chronic bronchitis asthma

Question 54

FEV1/FVC \>70 % with low DLCO

Answer 54

ILD sarcoidosis asbestosis heart failure

Question 55

FEV1/FVC \>70% with normal DLCO

Answer 55

musculoskeletal deformity neuromuscular disease

Question 56

normal spirometry with low DLCO

Answer 56

anemia PE pulmonary HTN

Question 57

normal spirometry with increased DLCO

Answer 57

pulmonary hemorrhage polycythemia

Question 58

How does the ABG and physical exam differ for patients with CHF vs COPD?

Answer 58

ABG * CHF: hypoxia, hypocapnia, respiratory **alkalosis** _{^{(secondary to tachypnea)}} * COPD: hypoxia, respiratory **acidosis** PE * CHF: decreased breath sounds, bibasilar crackles, history of CAD, uncontrolled HTN, * COPD: widespread bilateral wheezes

Question 59

pt recently diagnosed with colon cancer presents with a sudden onset of severe dyspnea and L sided chest pain, followed by syncope. BP 86/50, P 120/min and regular. O2 sat 80% on RA, JVD 13cm diagnosis? what would you expect to see on further work-up of this patient?

Answer 59

**PE** **malignancy/pro-thrombotic state** + acute onset of dyspnea, chest pain, tachycardia, hypoxia, and clear lungs = PE patients with an acute massive PE can present initially with **syncope & hypotension** (due to low arterial perfusion) TTE: **RV dilation & failure** due to **RVOT obstruction & increased PVR** EKG: **RBBB and R axis deviation**

Question 60

rapid association: patient on anticoagulation presents with arterial + venous thrombsis

Answer 60

heparin induced thrombocytopenia type 2 ("two types - immune-mediated) **venous** thrombosis can lead to DVTs, PE, skin necrosis **Arterial** thrombosis can lead to acute limb ischemia, organ infarction (mesentery, kidney), and stroke

Question 61

64 M with type II DM, HTN, HLD, HT, and CKD presents with sharp, L sided CP for the last 24hrs that is worsened by deep breathing and relieved by leaning forward. PE shows friction rub at LLSB, EKG shows asymmetric T-wave inversion Glu 248, Na 135, K 5.4, BUN 96, Cr 5.1 Diagnosis and management?

Answer 61

**uremic pericarditis** common in patients with CKD, esp those with BUN \>60 mg/dL does not present wtih classical EKG findings of pericarditis (diffuse ST elevations) treatment: **dialysis**

Question 62

type of murmur that is typically auscultated in IVDU patients

Answer 62

tricuspid regurgitation - **holosystolic murmur** that increases with inspiration

Question 63

first-line therapy for controlling anginal symptoms and improving exercise tolerance in _stable_ angina pectoris alternatives to patients with contraindications to ß blocker therapy (hypotensive, bradycardic)

Answer 63

ß blockers - reduce myocardial oxygen demand by decreasing the HR and myocardial contractility alternatives: **long-acting nitrates** (isosorbide dinitrate or mononitrate) or **Ca channel blockers** (diltiazem, felodipine)

Question 64

pt presents with exertional SOB, pounding heart sensation esp if he lays on his left side, and a BP 150/45

Answer 64

Aortic regurgitation "pounding heart sensation" = AR results in increased LVEDV, resulting in an enlarged LV that is closer to the chest wall, esp in the L lateral decubitus position widened pulse pressure (150/45) exertional dyspnea = insufficient delivery of O2 to peripheral tissues

Question 65

T/F patients suffering from acute pain s/p injury should receive the same standard of pain management regardless of addiction history

Answer 65

TRUE ex: patient with an extensive history of opioid abuse should still get IV morphine if he is suffering an acute, severe pain

Question 66

Patient receiving blood transfusion suddenly develops wheezing and progresses to respiratory distress. He becomes hypotensive and soon loses consciousness what type of patients is this reaction most common in? what should you do next?

Answer 66

**anaphylactic shock** common in patients with **IgA deficiency** due to the presence of **anti-IgA IgG antibodies** **stop transfusion -\> administer Epi IM**, vasopressors, histamine blockers, steroids, mechanical ventilation

Question 67

most common adverse reaction to blood transfusion when and why does it occur?

Answer 67

febrile non-hemolytic transfusion reaction occurs within **1-6 hours** of transfusion occurs because during blood storage, leukocytes release cytokines that when transfused, cause transient fevers, chills, malaise

Question 68

rapid association: boggy and erythematous nasal mucosa how do patients typically present? treatment?

Answer 68

non-allergic rhinitis (NAR) aka vasomotor rhinitis nasal congestion or stuffiness, post-nasal drip (dry cough), no specific identifiable triggers IN antihistamine + steroids

Question 69

how do you differentiate non-allergic rhinitis vs allergic rhinitis?

Answer 69

**non-allergic rhinitis -** nasal congestion/stuffiness, post-nasal drip (dry cough), and no identifiable triggers (typically negative serum radioallergosorbent test (RAST)) **allergic rhinitis** - eye symptoms, itching, sneezing, specific triggers

Question 70

patient presents with colicky flank pain with radiation to the scrotum; CT shows 4mm stones in the R upper ureter. next step in management?

Answer 70

**increase fluid intake \>2 L /day -** purpose is to increase the urinary flow rate an dlower the urinary solute concentration, thereby preventing stone formation

Question 71

where is brocas area located? associated symptoms?

Answer 71

dominant frontal lobe broken speech PLUS contralateral weakness of the face/extremities due to its proximity to the motor cortex and conjugate gaze deviation to the side of the leson

Question 72

when is an endoscopy vs PPI indicated for a patient with GERD?

Answer 72

**endoscopy** if there are "alarm symptoms" - dysphagia, odynophagia, weight loss, anemia, blleeding, recurrent vomiting, male \>50, history of smoking **PPI** if patients do not meet initial endoscopy criteria

Question 73

acute management of patients who present with cluster HA prophylactic management?

Answer 73

100% oxygen = most rapid acting and effective in aborting the pain during an acute attack verpamil = prophylaxis

Question 74

what is the hemi-neglect syndrome? where is the lesion typically located?

Answer 74

patient neglects the LEFT side of a space and responds only to stimuli that comes from the RIGHT side (ie patients may shave only the right side of their face, comb the right side of their hair, etc) lesion in RIGHT (non-dominant) parietal lobe, which is responsible for apatial organization

Question 75

patient with acne vulgaris and dysmenorrhea started taking oral contraceptives and becomes icterus. Liver biopsy shows dark granular pigment in hepatocytes

Answer 75

**Dubin Johnson Syndrome -** disorder of bile secretion that results in conjugated hyperbilirubinemia; liver is **B-L-A-C-K**! (pigmented granules are _not_ seen in the hepatocytes of Rotor syndrome)

Question 76

which nerve dysfunction is most likely responsible for impaired corneal sensation secondary to corneal abrasion?

Answer 76

trigeminal (V1), specifically to the nasociliary nerve mediating teh afferent limb of the corneal reflex

Question 77

patient recently diagnosed with systemic sclerosis presents with HA, increasing dyspnea, malaise, and nausea. BP 235/117, P 120, Hg is 6.9, Plt 57K, Cr 3.8 diagnosis? what is likely to be seen on the peripheral blood smear?

Answer 77

**scleroderma renal crises -** HTN + AKI in the setting of systemic sclerosis, usually within the first 5 years of SSC diagnosis peripheral smear: schistocytes + thrombocytopenia

Question 78

2 diagnostic tests for Multiple Sclerosis

Answer 78

MRI +/- gadolinium oligoclonal IgG bands on CSF analysis

Question 79

patient presents with transient monoccular vision loss, family history of stroke, and carotid bruit

Answer 79

**fibromuscular dysplasia** - non-inflammatory/non-atherosclerotic condition caused by abnormal cell development in the arterial wall taht can lead to vessel **stenosis, aneurysm, or dissection**

Question 80

fibromuscular dysplasia what is it? who does it usually affect? which arteries does it normally affect and what type of symptoms present? diagnostic test?

Answer 80

non-inflammatory/non-atherosclerotic condition caused by abnormal cell development in the arterial wall taht can lead to vessel **stenosis, aneurysm, or dissection** affects **women 15-50** commonly involves **renal arteries -\> HTN** **carotid + vertebral arteries -\> HA, pulsatile tinnitis, dizziness, TIA, stroke, amaurosis fugax** diagnostic test: **CT angio of the abdomen or duplex US**

Question 81

after a central venous catheter is placed, what should be the next step in management?

Answer 81

get a portable CXR to confirm proper placement of the catheter tip and absence of complications\* before administering drugs or other agents through the catheter ^{*arterial puncture, pneumothorax, hemothorax, thrombosis, air embolism, sepsis, vascular perforation, myocardial perforation leading to tamponade*}

Question 82

inheritance pattern & clinical features of patients with hemophilia A & B

Answer 82

X-linked recessive - occurs exclusively in males hemarthrosis intramuscular hematoma (bleeding into skeletal muscle) GI/GU bleeding prolonged PTT

Question 83

best diagnostic test patient who complains of hearing loss and has multiple cafe au lait spots

Answer 83

acoustic neuroma -\> **MRI + gadolinium enhancement**

Question 84

histological ∆ btwn Crohn's and UC

Answer 84

**Crohns: non-caseating granulomas** other features of Crohns: can affect any part of the GI tract but commonly limited to terminal ielum, transmural involvement, skipped lesions, cobblestone appearance, creeping fatty appearance of mesentary, fistulas, fissures, perinanal disease **UC: crypt abscesses** other features of UC: limited to the colon/rectum but may sometimes involve the terminal ileum (backwash ileitis); abdominal pain + bloody diarrhea

Question 85

most common cause of lower GI bleed in an elderly patient

Answer 85

diverticulosis - painless bleeding colon cancer ischemic colitis brisk upper GI bleed (usually presents with hematemesis as well) colonic AVM coagulopathy

Question 86

∆ btwn diverticulosis and diverticulitis

Answer 86

**diverticulosis - non-inflammed diverticula, painless bleeding** (caused by diverticula eroding into a penetrating colonic artery, resulting in a profuse self-limited bleeding per rectum) ## Footnote **diverticulitis - obstruction of diverticula resulting in abd pain + infectious sx, usually w/o bleeding**

Question 87

68 M with COPD, CHF, CAD presents wtih dyspnea, productive cough, fever x3 days. CXR shows lower lobe infiltrate. diagnosis? management?

Answer 87

community acquired pneumonia mgmt: determine if he/she can be managed as out-pt or in-pt using the CURB-65 algorithm (1 pt each, ≥2 = inpatient trmt, ≥4 = ICU admit) **C**onfusion **U**remia (BUN \>20) tachypnea (**R**R \>30) hypotension (**B**P \<90/60) Age \>**65**

Question 88

common causes of CAP treatment?

Answer 88

**S. pneumoniae** **Haemophilius** **Atypical organisms (mycoplasma)** for heatlhy patients with CAP: **doxycycline or macrolides** for patients requiring hospitalization: **broad-spectrum fluoroquinolone (levofloxacin, moxifloxacin)** _or_ **ß-lactam + macrolide**

Question 89

common acid/base abnormality caused by PE

Answer 89

respiratory alkalosis - patient hyperventilates to overcome hypoxia and V/Q mismatching

Question 90

what is the mechanism behind heparin-induced thrombocytopenia?

Answer 90

heparin binds to platelet factor 4 (PF4), which triggers IgG antibodies to bind to it. This complex then activates platelets by binding to the platelet Fc receptor -\> release of procoagulants -\> platelet aggregation, thrombin formation -\> **arterial + venous thrombosis** Splenic macrophages removes the activated platelet-antibody-heparin-PF4 complexes -\> **thrombocytopenia**

Question 91

what is the serum and urine osmolality in patients with SIADH?

Answer 91

low plasma osmolality (\<280 mOsm/kg) high urine osmolality (\>100-150 mOsm/kg) ^{ADH draws water out of the collecting ducts -> thereby diluting serum but concentrating urine}

Question 92

patient develops an acute onset of chest pain; EGK shows STEMI in leads II, III, aVF; PE: holosystolic murmur at the apex, bibasilar crackles diagnosis?

Answer 92

mitral regurgitation secondary to papillary muscle displacement, which can occur acutely as in this case or 2-7 days after the infarct due to papillary muscle rupture ^{the papillary muscle displacement can lead to an abrupt diastolic volume overload, which causes elevated LVEDP/LV filling pressure -> this pressure is reflected back into teh L atrium and pulmonary circulation, and is responsible for the signs and symptoms of acute pulmonary edema and CHF}

Question 93

40 yo alcoholic presents to the ED with confusion, gait instability, and horizontal nystagmus and conjugate gaze palsy in both eyes with absent ankle reflexes in both legs. vitamin deficiency?

Answer 93

This triad of encephalopathy, oculomotor dysfunction, and gait ataxia is classic for **Wernicke's encephalopathy**, which is the result of **thiamine (B1) deficiency** secondary to chronic alcoholism ^{DO NOT CONFUSE WITH COBALAMIN B12 DEFICIENCY, which also causes neurologic deficits, including impaired vibratory and position sense and gait abnormalities (due to DCML degeneration) and mental status changes. Oculomotor symptoms are usually absent}

Question 94

alternatives to heparin in a patient who has developed HIT

Answer 94

direct thrombin inhibitors (argatroban, bivalirudin) synthetic pentasaccharide (fondaparinux)

Question 95

Management of a patient with an EKG that shows a first-degree AV block (prolonged PR interval) with normal QRS duration What if it showed a first-degree AV block with prolonged QRS duration?

Answer 95

**First degree AV block with _normal_ QRS duration**- due to delayed impulse transmission from atria -\> ventricles, usually at the AV node; requires **no further evaluation** unless there is significant bradycardic symptoms (ie syncope) **First degree AV block with _prolonged_ QRS duration (\>120 msec)**- due to conduction delay below the AV node, usually in bundle branches; **requires further evaluation** to determine the site of conduction delay because these have an unpredictable progression to advanced 2nd-deg or complete heart block