Medicine UW Journal

Question 1

What are the 3 most common causes of aortic stenosis in the general population?

Answer 1

1. Senile calcific aortic stenosis (usually in Pts >70 years old)
2. Bicuspid aortic valve (usually in Pts <70 years old)
3. Rheumatic heart disease

Question 2

How could you tell the difference b/w a heart murmur due to hypertrophic cardiomyopathy as opposed to aortic stenosis?

Answer 2

Both can cause a systolic crescendo-decrescendo murmur + S4, but:

Hypertrophic cardiomyopathy: best heard in lower left sternal border

Aortic Stenosis: best heard in right upper sternal border + radiation to carotid arteries

Question 3

Which Pt population is recommended to be screened for AAA’s? By what screening modality?

Answer 3

• Males who are active or former smokers aged 65-75
• One-time abdominal US to look for AAAs > 5.5cm

Question 4

A Pt w/ thrombocytopenia, macrocytosis, elevated liver transaminases + heart failure is most likely suffering from what condn? How can it be reversed?

Answer 4

• Dilated cardiomyopathy secondary to alcoholism
  
  • Abstinence from alcohol can reverse heart failure if implemented early

Question 5

What kind of arrhythmia is indicated by this ECG?

Answer 5

A-fib

Question 6

Pulsus paradoxus can be found most commonly due to which 3 condns?

Answer 6

1. Cardiac tamponade (and other condns that cause pericardial effusion)
2. Severe asthma
3. COPD

Question 7

What are 3 physical exam findings suggestive of severe aortic stenosis?

Answer 7

1. Delayed and diminished carotid pulse (pulsus parvus and tardus)
2. Presence of single and soft S2
3. Mid- to late-peaking systolic murmur w/ max intesity @ 2nd right intercostal space radiating to carotids

Question 8

What is the mechanism for cutaneous flushing and pruritus caused by high-dose niacin therapy to treat lipid abnorms?

Answer 8

High dose niacin is thought to release histamine and prostaglandins and thereby cause vasodilation (hence not a true hypersensitivity rxn); ASA 30 mins prior to taking niacin can reduce the peripheral vasodilation

Question 9

Which two physical maneuvers allows hypertrophic cardiomyopathy and mitral valve prolapse to be heard more prominently?

Answer 9

Valsalva (Decrease preload + Increases afterload) and Abrupt Standing (decreases preload + decreases afterload)

Think of it as in order to hear HCM and MVP better, you need the left heart to be quiet (MVP iand HCM are best heard when there is decrease preload to the left heart; MVP is also heard best when there is increased afterload)

Question 10

State the changes seen in preload and afterload due to these physical maneuvers:

• Inspiration
• Valsalva
• Abrupt standing
• Squatting
• Passive leg raise
• Handgrip

Answer 10

• Inspiration: Increase preload to R heart; Decrease preload to L heart
• Valsalva: Decrease preload; Increase afterload
• Abrupt standing: Decrease preload; Decrease afterload
• Squatting: Increase preload; Increase afterload
• Passive leg raise: Increase preload
• Handgrip: Increase afterload

Question 11

Mutations in which two genes account for ~70% of identifiable mutaitons in Pts w/ hypertrophic cardiomyopathy?

Answer 11

Mutations in: cardiac myosin binding protein C gene & cardiac beta-myosin heavy chain gene

Question 12

What disease process is associated w/ a Pt who has a Hx of infective endocarditis that newly develops AV block?

Answer 12

Perivalvular abscess, which extends into adjacent cardiac conduction tissues

Question 13

An elevated BNP and audible S3 indicate what cardiac dysfxn?

Answer 13

Left ventricular systolic dysfxn (dilated cardiomyopathy)

Question 14

What is the most useful intervention to improve function capacity and reduce symptomatic claudication in PAD?

Answer 14

Graded exercise

Question 15

What kind of obstructive disease could cause flank/abdominal pain that radiates to the perineum and medial thigh?

Answer 15

Ureteral calculi

Question 16

What is the imaging modality of choice for nephrolithiasis/ureterolithiasis?

Answer 16

US or noncontrast spiral CT (US more preferred due to lower radiation exposure)

Question 17

How can you differentiate a malignant renal mass from a simple renal cyst?

Answer 17

Malignant renal mass will be multilocular, have irregular walls, thickened septae, and have contrast enhancement

Question 18

What kind is the most probable organism if a Pt presents w/ atypical CAP + GI and CNS symptoms?

Answer 18

Legionella (also you might see hyponatremia)

Question 19

What is the intial treatment for severe hypovolemic hypernatremia?

Answer 19

Isotonic 0.9% saline IV (to correct the hyperosmolality gradually while normalizing the Pt’s volume status)

Question 20

Mild hypovolemic hypernatremia can be corrected with what type of IV fluid?

Answer 20

5% dextrose in 0.45% saline

Question 21

What type of syncope characteristically entails a middle age/older male who loses his consciousness immediately after urination or during coughing fits?

Answer 21

Situational syncope (due to autonomic dysregulation)

Question 22

What secondary bacterial pneumonia can cause necrotizing pulmonary bronchopneumonia w/ multiple nodular infiltrate that can cause pneumatocoeles (small abscesses)

Answer 22

Staph aureus

Question 23

What benign tumor of the liver is associated with oral contraceptives in young and middle-aged women?

What is the imaging modality of choice?

Answer 23

• Hepatic adenoma
• US will show a well-demarcated hyperechoic lesion

Question 24

Acute HIV infxn can be differentatiated from mononucleosis by which additional clinical symptoms?

Answer 24

Acute HIV (w/n first 6 mo of infxn) can present w/ mono-type syndromes (fever, night sweats, arthralgias, and lymphadenopathy) + painful mucocutaneous ulcerations (a characteristic manifestation), skin rash, and prolonged diarrhea

Question 25

This Pt complains of weakness, dizziness, and back pain. He also takes warfarin for chronic anticoagulation. What is the Dx based on the abdominal CT?

Answer 25

Retroperitoneal hematoma

Question 26

What is the most likely cause of hyponatremia and urine osmolality <100 mOsm/kg in Pts w/ uncontrolled psychiatric condns?

Answer 26

Primary polydipsia (Pts keep drinking water and the kidney can’t keep up in throwing out the water)

Question 27

What is the first-line treatment for Pneumocystis pneumonia in a Pt who has PaO2 <70mmHg on room air or A-a gradient >35?

Answer 27

TMP-SMX + Corticosteroid (e.g. prednisone)

Pts initially have antibiotic-induced worsening of resp fxn due to the inflamm effects of dead organisms in lung tissue

Question 28

What is the most appropriate next step in evaluating a Pt w/ probable BPH after taking a Hx and doing a rectal exam?

Answer 28

Urinalysis +/- PSA (get PSA levels if Pt has > 10 year life expectancy to screen for prostate cancer)

Question 29

What infxous agent should be suspected if an Asian Pt presents w/ an insensate, hypopigmented patch of skin? How do you definitively Dx it?

Answer 29

• Mycobacterium leprae –> leprosy
• Look for acid-fast bacilli on skin biopsy

Question 30

What intervention is indicated for men w/ asymptomatic carotid artery stenosis of 70-99%?

Answer 30

Carotid endarterectomy (CEA is basically indicated for anyone who has high degree of carotid stenosis)