Missed questions Flashcards
Drugs that cause folic acid deficiency
Phenytoin
Trimethoprim (dihydrofolate reductase)
Methotrexate (DHFR) leucovorin rescue
Pruritis after shower, dizziness, headache, HTN, facial plethora, hypercellular BM
PCV
- Primary = LOW EPO, JAK2 mutation
- Secondary = Normal/high EPO, hypoxemia, renal tumor, hepatic tumor, testosterone replacement
- can precipitate GOUT attack
Immune-mediated drug reaction by captopril
Membranous GN
35 weeks gestation, HTN, dec urinary output, thrombocytopenia
Preeclampsia w/ severe features (pul edema, LFTs, SBP >160, inc Cr) –> hydralazine or labetalol then mag sulfate
93 y/o vaginal bleeding, odor, mass, no mets
SCC –> resect 2cm or poor surgical candidate
Combination chemotherapy stage III, IV
High non-response rate, use only hospital-based patients, loss of study patients type of bias
Selection bias
Improves mortality in CHF
ACE, BBs, spironolactone
Exudative pleural effusions
Protein >0.5, LDH >0.6 that of normal
Infection, auto-immune, neoplasm
INC CAPILLARY PERMEABILITY
Low TSH, high T4, T3, no signs of Grave disease, low RAIU
Facticious or exogenous thyrotoxicosis = LOW serum thyroglobulin
Low TSH, high T4, T3, no signs of Grave disease, high RAIU
Diffuse = Grave Nodular = toxic adenoma or mulitnodular goiter
Tachycardia with buried P-waves, chest pain, diaphoresis, normal BP, hx anxiety, dizziness
SVT = Adenosine
Bone pain, difficulty walking, cramps, pseudofractures
Osteomalacia = INC PTH, alk phos + LOW Ca, phos, 25D-OH
- malabs, chronic liver, kidney, intestinal bypass, celiac
- # 1 = vit d deficiency
Fever, back pain w/ local tenderness, recent UTI, NO leukocytosis, INC ESR/CRP, normal x-rays
Osteomyelitis –> MRI –> CT guided aspiration
White edematous retina following retinal arterioles, curtain falling over eye
Retinal emboli –> carotid doppler
Painless loss of vision, boxcar segmentation, cherry fovea, pallor or hyperemic disc
CRAO
Mallory bodies and neutrophilic infiltrate on liver bx
Alcoholic hepatitis = completely reversible w/ etOH cessation
Regenerative nodules = cirrhosis = irreversible
Encapsulated yeast
Cryptococcus neoformans = amphotericin B + flucytosine –> fluconazole for 1 yr
Itraconazole does NOT cross BBB
DOC for Lyme disease < 8/yo
Amoxicillin or cefuroxime
HIV pt, pancytopenia, palatal ulcers, hepatosplenomegaly, intetstitial pneumonitis
Histoplasma
New DOE, swelling of head, neck, arms, plethora of face, no LE edema, ascities
SVC syndrome –> CXR for NHL or lung CA
DVT –> heparin therapy –> 6th day new right sided weakness, aphasia, 50,000 platelets, skin necrosis, normal CT, heart RRR, no fibrin split products
HIT type 2 (antibody platelet activation)
- –> binds PF4 –> IgG –> activates Fc receptor leading to platelet activation
- –> ARTERIAL or venous THROMBOSIS
HIV esophagitis work-up
- Candida –> oral fluconazole
- esophagoscopy + bx, cytology, culture w/o improvement
HSV = round/ovoid ulcers + perioral ulcers CMV = linear ulcers
Common findings in anorexic patients
- Osteoporosis
- Elevated cholesterol and carotene
- Prolonged QT
- Euthyroid sick syndrome
- HPA axis - amenorrhea, anovulation, dec estrogen
- HypoNa
- Small for gestational age baby, intellectual impairment, miscarriage, depression, hyperemesis, c/s
Southern US + tick bite + thrombocytopenia + leukopenia, fever, malaise, inc LFTs, inc LDH, intracytoplasmic morulae
Ehrlichiosis –> doxycycline
32 w/ hx seizures, migraines, bipolar –> slurred speech, very drowsy, unsteady gait, normal resp, normal pupils, no nystagmus
Benzo overdose
65 w/ PNA sx + very high WBC, 84% lymphocytes w/ smudge cells.”
CLL –> flow cytometry
RBCs 1-6hrs later fever, chills, malaise
Nonhemolytic transfusion rxn = leukoreduction (red HLA, CMV)
Anaphylaxis w/ PRBCs = IgA deficiency = wash cells 1st
Eczematous, itchy rash over nipple, no other hx of skin problems
Paget disease of breast = underlying adenocarcinoma
Truncus arteriosus, micrognathia, no thymus, cleft lip
DiGeorge = hypoCa
Thickening of pre-vertebral tissues, neck pain, fever next step
IV abx, IVFs & surgical drainage
Uncontrolled DM, weight loss, neuropathy, 3months of N/V, dec appetite
Gastroparesis —> gastric scintography
- Hepatitis uses reverse transcriptase
2. Hepatitis coats itself in LDL
- HBV
2. HCV –> IF-a
Infective endocarditis bugs
- dentition
- IVDU
- UTI
- HACEK group, strep viridan/sanguis
- SA, staph epi/CoagN
- Enterococcus faecalis
Tx of hypercalcemia
Asx = avoid thiazides, lithium, dehydration Sx = nothing immediate or see severe Severe/malignancy = NS + calcitonin short term --> zoledronic acid long term Granulomatous = steroids to reduce VitD
Shoulder dystocia –> extended forearm, MCP, flexed PIP/DIPs, horner syndrome, ABSENT grasp reflex
C8, T1 injury = Klumpe’s palsy
—> massage and gentle PT
COPD w/ inhaled salmeterol, duonebs, theophylline –> recent URI w/ cipro –> HA, N/V, insomnia, multifocal atrial tachycardia
Theophylline toxicity –> check serum level
1st febrile UTI <24mo work-up
7-14d abx
renal and bladder US (also if recurrent or do not respond to abx)
Physiology of CHF w/ peripheral edema
Dec circulating BV –> inc angiotensin & aldosterone release –> constrict renal arterioles & reabsorb salt and water –> increased BV which exacerbates CHF further
Muscle aches and pains, HIGHLY ELEVATED CPK, mild elevation in LFTs
Stop statins - muscle injury –> rhabdomyolysis & RF
Hazard ratio >1
More likely to occur in tx group
1 = no difference
<1 = more likely in control
Teen, gradual difficulty walking, speech problems, falling down, scoliosis, hammer toes
Freidrich ataxia
- Cardiomyopathy –> death
Gestational bleeding
- HTN, contractions
- Painless, C/S, smoking, multiple gestation
- Painless bleeding + rapidly deteriorating fetal tones
- Abruption
- Previa
- Vasa previa
Young obese female on OCPs, steroids, Vit A, tetracycline, has dull HA for 3 weeks, papilledema
Benign intracranial HTN –> blindness
1. weight reduction, acetazolamide then shunt and optic nerve fenestration
A.A. woman with pelvic heaviness + constipation + urinary frequency and posterior uterine mass and enlargement and HEAVY, prolonged periods WITHOUT spotting
Uterine leiomyoma/fibroid
Hypotension, bradycardia, cold, clammy, AV block - unresponsive to IVFs and atropine
Glucagon
- BB overdose (w/ wheezing), CCBs
A.A. male w/ fam hx of fatal blood disorder, recurrent otitis media, HAV –> nocturia, frequency
Hyposthenuria - sickling in vasa recta impairs water re-absorption
HSM, anemia, thrombocytopenia, night sweats, HA, dizziness, visual problems, pain and numbness in extremities, IgM spike
Waldenstrom’s macroglobulinemia
- MM have IgG or IgA
- MGUS = Asx
Winter’s formula for acid-base compensation
PCO2 = 1.5 (HCO3-) + 8
Post- transplant fever, chills, sputum production + RLL consolidation + branching, beaded gram + rods
Nocardiosis (partially acid-fast) —> TMP-SMX
Anterior MI + muffled heart sounds, S3, bibasilar crackles and dyspnea next step
Flash pulmonary edema –> lasix –> dec preload, pulm capillary pressure
Avoid BBs in this setting
When can exposure odds ratio from a case-control study = relative risk?
Prevalence of disease is low
S/P CABG with ventricular rhythm narrow QRS irregular tachycardia, hypotensive
AFIB –> DC cardioversion
Failure to pass meconium, 1st step XR –> marked bowel dilation & r/o pneumoperitoneum next step
Contrast enema –> microcolon for CF –> Gastrografin enema
Central/above pons Facial nerve palsy vs. peripheral/below pons
Central = CL weakness + preserved forehead, eyebrow, eyelid function
Co-morbidities in Turner syndrome
Osteoporosis
Coarctation of aorta
Congenital lymphedema (non pitting), short 4th digit, nail dysplasia, horseshoe kidney
Young male anterior mediastinal mass + bHCG + AFP
NON-seminimatous germ cell tumor (AFP+)
Acyclovir + acute renal failure cause
Insoluble –> crystalluria –> renal tubular OBSTRUCTION
Mood disorder and paranoia, hallucinations –> mood improves but paranoia remains
Schizoaffective disorder
Tx OCD
SSRIs
When to hospitalize anorexic pt
Dehydration, hypoK, hypoPhos, bradycardia, severe weight loss —> refeeding syndrome w/ electrolyte abn, arrhythmia and heart failure
Tx in anorexia and bulimia
1st is nutritional and CBT
Buproprion is CI d/t SEIZURE
anorexia = olanzapine bulimia = SSRI
Dysparenunia, dysmenorrhea, DYSCHEZIA, cyclical pelvic pain, infertility, CMT
Endometriosis –> OCPs + NSAIDs
Unrelieved –> laparoscopy
Precursor to GB adenocarcinoma
Porcelain gallbladder
Cyanotic infant w/ LEFT axis deviation, no R waves in precordial leads, dec pulmonary markings, tall peaked P waves, LLSB holosystolic murmur
Tricuspid valve atresia
Conservative vs. laparoscopy in SBO
Laparoscopy
- tachycardia, leukocytosis, fever, acidosis, peritoneal signs
Inc QRS from 0.8 –> 0.13 with inc HR during stress test result of what drug?
Flecainide
- ventricular arrhythmia and SVTs like AFIB
- use-dependence block of Na channels
Post-partum patient, fever, chills, WBC 11,000, uterus firm, non-tender, bloody discharge with clots –> pale –> yellow/white next step
Reassurance
- lochia foul smelling = endometritis
- fever normal in first 24hrs or so
HL treated 20 years ago w/ chemo and radiation –> now circular mass on xray dx?
Secondary malignancy
- also breast, thyroid, bone, GI
Russian immigrant, fatigue, cough, fever, weight loss, upper lung lesion + hyperNa, hypoK, hypoglycemia, eosinophilia acid-base abnormality?
Normal anion gap metabolic acidosis d/t primary adrenal insufficiency
Mechanism of hypoxia in pt with AIDS, interstitial crackles
PCP –> Dec A-a oxygen gradient
HIV pt with hearing loss + dull hypomobile TM
Serous/non-infectious otitis media
- HIV LAD or obstructing lymphoma
Manic episode on Lithium + high-risk behaviors, no drug use
Anti-psychotic + hospitalization –> check lithium level
Tx duodenal hematoma
NG tube + TPN —> resolves in 1-2wks
2x2cm midline, hard, non-mobile mass on hard palate, no drug use
Torus palatinus = congenital
Lack of fetal movement felt for 2 days next steps + no doppler tones
Ultrasound for fetal heart movement –> autopsy to identify cause
SLE on prednisone, normal menstruation, monomorphous pink papules w/o comedones
Steroid acne
U/L cervical adenitis in kid, no pet or TB exposure = tx?
I&D + Clindamycin
- staph and strep #1
Kid w/ fever, nasal discharge, fatigue + 2+ urine protein, no other abn
Repeat dip w/ >2 specimens
Normal proteinuria in kids - fever, exercise, stress, dehydration
Prevent hemorrhagic cystitis w/ chemo
Mesna = d/t cyclophosphamide
HSM, cervical LAD, hypotonia, regression of milestones, cherry red macula
Niemann-pick = sphingomyelinase
Tay-sachs = Hyperacusis and seizures
Wide matching QRS complex @ 100bpm following MI, stable patient next step
Sustained monomorphic V-tach
- stable = amiodarone
- unstable = cardioversion
If narrow PSVT = carotid massage, cold water immersion = affects AV node conductivity
Precocious puberty, large cafe-au-lait spots w/ irregular borders, multiple bone defects, moon-like face
McCune-Albright
- Precocious puberty
- Pigmentation
- Polyostotic fibrous dysplasia
DMARD SEs
- MTX
- Hydroxychloroquine
- TNF-a
- Liver, oral ulcers/stomatitis, cytopenia, alopecia
- Retinopathy
- Infection/TB, malignancy, CHF
HIV + acid-fast oocysts in stool + diarrhea
Cryptosporidium parvum»_space;> Isospera belli
How to unmask confounding variables
stratified analysis - etOH vs. non-etOH vs. smoking and non-smoking –> cirrhosis
Watery diarrhea, flushing, valvular heart disease
Carcinoid syndrome
- tryptophan –> serotonin production in carcinoid INSTEAD of —> NIACIN
Pyogenic liver abscess bug
Bacteroides
Test sensitive for rotator cuff pathology besides arm drop
Neer test - affected limb’s hand to opposite should and raise elbow –> pain –> inject lidocaine for relief
Kid DM-1 + weight loss, low MCV anemia, erythematous vesicles on extensor surfaces, stool occult (-)
Celiac - anti-tissue transglutaminase ab
1 complication of sickle cell TRAIT
Hematuria
- also isothenuria –> polyuria, nocturia
Tx endometritis
Polymicrobial = Clinda + Gent
Re-warm frostbite
Warm water
1 injury in supracondylar fx
Brachial artery
Chronic HA + painless hematuria cause?
Papillary necrosis d/t analgesic nephropathy - vasoconstriction in vasa recta
Address anxiety by substituting behavior that is the exact opposite of own unacceptable feelings
Reaction formation
Double vision after reading, cramps in jaw after chewing a steak, voice/throat funny after talking on the phone for a while, normal CPK, normal reflexes
Myasthenia gravis –> CT chest to r/o thymoma
Signs of cholinergic toxicity/organophosphate poisoning
Bradycardia, miosis, fasciulations, salivation, lacrimation, diarrhea, urination —> atropine & remove clothing
Older man w/ back pain w/ normal exam + anemia, Inc Cr, Inc Ca, Inc ESR, Inc total protein w/ normal albumin
Multiple myeloma –> serum immunoelectrophoresis
Nagging epigastric pain + weight loss, jaundice, food intolerance, enlarged non-tender GB
Pancreatic CA = dilation of intra and extrahepatic ducts
Cafe au lait, macrocephaly, feeding problems, optic glima, short stature and learning disabilities
NF-1
Number needed to treat
1/ARR
S3
Elevated LV filling pressure = CHF
Homeless man hematuria, flank pain, ARF, hypoCa, metabolic acidosis
Ethylene glycol intoxication –> fomepizole
Inc leukocyte alkaline phosphatase
Leukemoid rxn d/t infection or inflammation
1st step in torticollis?
XR to r/o AA subluxation, retropharyngeal abscess
Prurititis at night in middle aged woman, destruction of intrahepatic bile ducts, IgM, xanthelasmas
PBC = anti-mitochondrial abs —> UDCA
20+ yr Ankylosing spondylitis + fall –> severe back pain dx?
Vertebral fx
Hypertonia, hyperreflexia in legs b/l, feet pointing down and in in newborn infant
Cerebral palsy = PREMATURITY infection, hemorrhage, drug esp in pt with no dystrophic features
HA, retro-orbital eye pain, blurred vision, constipation, urinary retention in Parkinson pt d/t what med?
Trihexyphenidyl - anti-cholinergic excess with acute glaucoma
Complication following infectious mononucleosis
Auto-immune hemolytic anemia & thrombocytopenia d/t IgM cold agglutinin + anti-I antibodies (Coombs +)
Test for lactose intolerance
Hydrogen breath test
Hexagonal urine crystals + positive urine nitroprusside
Cystinuria - amino acid transport
IE w/ strep mutans highly susceptible to PCN drugs of choice
IV PCN G or IV ceftriaxone, NOT oral
Tx hypovolemic hyperNa
NS
External effect + or - affects outcome (family hx)
Effect modification (Vs.confounding)
Cough, hemoptysis, chronic purulent rhinosinusitis, ulcer with rolled, undermined borders on leg , RBC casts, protienuria
Wegeners - cyclophosphamide
Flank pain w/ crohn disease or other fat malabsorption syndrome
Hyperoxaluria - Ca binds excess fat in gut and not oxalate
Effect of BB therapy in Pheochromocytoma
Rapid increase in BP d/t unopposed alpha vasoconstriction
Chest pain, NSTEMI, dilated pupils, atrophic nasal mucosa
Cocaine use –> benzo then aspirin, nitrates and CCBs
BBs are CI
PPx for uric acid stones
Hydration
Potassium citrate to alkalinize urine
Sequelae of seizures >5 min, status epileptics, recurrent seizures etc
Cortical atrophy/laminar necrosis - hyper intensity on MRI
Spherocytosis
+ Coombs
- Coombs
Auto-immune hemolytic - warm (IgG)
Hereditary - osmotic fragility
Leukocytosis, inc segmented neutrophils, bands, older woman w/ weight loss & night sweats
CML = LOW leukocyte alkaline phosphatase + Philadelphia Chr
Hearing loss, tinnitus, hold cell phone in other ear, EAR FULLNESS, spinning for 1-2hrs
Meniere disease - endolymph, inner ear disease
Kidney finding w/ HBV
Membranous
Cause of distended bowels s/p vertebral fx or retro peritoneal hemorrhage, absent bowel sounds
Paralytic ileus
Pseudo-obstruction = only large bowel dilated, tympanic hyper bowel sounds
Inc ventricular wall thickness w/ normal dimensions, easy bruising, normotensive, protienuria, waxy thickening of skin + diastolic CHF
Amyloidosis - tissue bx abd fat pad
Precocious puberty or regression of menopausal sx + bleeding + estrogen producing (breast, hair development) U/L solid pelvic mass
Granulosa cell tumor
Sertoli-leydig produce masculinization
Pre-menopausal woman done having children w/ complex hyperplasia w/o atypia next step?
Cyclic progestin
Psoas abscess 1st step?
CT abd
(-) CT –> laparoscopy
Percutaneous drainage
Hematogenous spread from skin = SA
HOCM murmur and tx
INC w/ standing or valsalva = dec VR/preload
Tx = BBs or diltiazem to slow HR and prolong diastole for better filling
Broad flat t-waves, U-waves, ST-depression, weakness, fatigue, muscle cramps cause
HypoK
Isolated systolic HTN cause
Rigid arterial walls/decreased elasticity
anti-CCP abs
RA
HIV, A.A, nephropathy
FSGS
HBV nephropathy
Membranous
HCV, jaundice, confused, lowNa and K, Normal UA, Cr 3.5 –> NS bolus has no chg in Cr
Hepatorenal syndrome –> infection, hemorrhage & death
LIVER TRANSPLANT
Tx HyperNa
Euvolemic = water Hypovolemic = NS then D5W
Mech of CO hypoxia, acidosis
Dec DELIVERY of O2 to tissues - unable to unload O2
Young school teacher w/ acute symmetric b/l arthritis of MCP, PIP, wrists, knees, morning stiffness 10-15min
B19 infection
Tx acute HBV
Normal = IF-a
W/ HIV not on therapy = IF-a + emtracitabine + tenofovir
W/ HIV on therpay = lamivudine + adenofovir
Next step w/ LSIL
25-29 = colpo >30 = HPV --> colpo of +
Human & animal bite drug tx
Augmentin
Clinda + cipro if allergic
RAIU findings w/ hyperthyroidism
- Heterogenous
- Homogenous
- Focal
- NO uptake
- Toxic multinodular/Plummer’s disease
- Grave
- Functioning Adenoma
- Facticia or exogenous like struma ovarii or subacute thyroiditis
Cause of type 1 RTA
Non-anion gap metabolic alkalosis
Seen in Sjogren syndrome –> kidney stones
Distal tubule can’t excrete H+ –> high urine pH >5.5
Cause of type 2 RTA
Non-anion gap metabolic alkalosis
Proximal tubule can’t re-abs PHOSPHATE, normal urine pH
Cause of type 4 RTA
Can’t secret K+ = lost effect of aldosterone –> HYPOTENSION
Nail finding w/ psoriasis
Onycholysis
Thin concave nails w/ raised ridges cause
Koilonchyia - iron deficiency
Work-up for Neutropenic fever
Blood, urine, sputum cultures & CXR –> Pip/tazo
Fever after abx = fungal –> amphotericin B
Poisonings
- HA, convulsions, GARLIC breath
- Bitter almond breath
- Hyperhidrosis, narrow vision, tachy, HTN, neuropathy
- Salivation, lacrimation, urination, blurred vision, brady
- Arsenic
- Cyanide –> amyl nitrite or thiosulfate
- Mercury –> succimer, dimercaprol, penacillamine
- Organophosphate –> atropine
Anemia in CKD/RF/ESRD
EPO deficiency - normocytic, normochromic
<30
SE - HTN, HA, flu
Infusion reactions
- F/C w/in 6hrs
- Fever, flank pain, DIC, RF w/in 1hr
- Fever, anemia 2-10 after infusion
- Angioedema, RDS w/in seconds
- Urticaria, flushing w/in hours
- RDS, pulmonary edema w/in 6hrs
- Febrile non-hemolytic (#1) = cytokines in stored blood
- Acute hemolytic = ABO mismatch, + Coombs
- Delayed hemolytic = anamnestic ab response
- Anaphylaxis = IgA deficiency
- Allergic = Recipient IgE
- TRALI = donor anti-leukocyte abs
Erythema multiforme vs.
SJS
Erythema multiforme - follows HSV infection, sudden targetoid lesions
SJS - sulfa, NSAIDs, phenytoin, sudden targetoid lesions + MUCOSAL involvement, AMS, hypotension, conjunctivitis, fever
Young male, morning back stiffness, bloody diarrhea, painful nodules on shins, anemia, P-ANCA
IBD - UC
Whipple procedure
Pancreatic CA in head
- remove pancreas, GB, duodenum, proximal jejunum and distal stomach
Next step in pt with atypical glandular cells (AGC) on cervical cytology
Colposcopy + endometrial bx
- AGC much more likely to be malignant and squamous cells
Goal BP for ppl >60 y/o
150/90
Night time teeth grinding + ear pain
TMJ dysfunction
Zoster + Bell Palsy
Ramsay-Hunt syndrome
Fasted –> large meal + RUQ pain, N/V cause
Biliary colic = viscous distention
Fxn of hormones during pregnancy
- hcg
- progesterone
- estrogen
- Maintain corpus luteum
- Inhibit contractions
- Stimulate prolactin
Infant w/ vomiting, poor weight gain, hypoglycemia, cataracts
Galactosemia = G1P-uridyl transferase deficiency
ONLY cataracts = galactokinase
CT w/ multiple hypodense, non-enhancing lesions w/ no mass effect in HIV pt
PML
CT w/ multiple ring-enhancing lesions in the basal ganglia
Toxo
CT w/ solitary, weakly-enhancing ring lesion, periventricular
Primary CNS Lymphoma = EBV DNA
LOW RAIU causes
Subacute painless thyroiditis Subacute granulomatous thyroiditis (DeQuervain) Iodine-induced Levothyroxine OD Struma ovarii
Age of spontaneous closure of umbilical hernia
1yr
3-4yrs, >2cm, larger = surgery
Enlarged rubbery goiter w/ anti-TPO abs sequelae?
Hashimoto –> LYMPHOMA
- suspect w/ rapid enlargement of thyroid, compressive sx, pseudocystic pattern on US
Conditions w/ inc BUN/Cr
Pre-renal renal failure
GI bleed
Steroids
Restrictions in exercise when pregnant
Multiple gestation, previa, aburption, fluid leak, preeclampsia
No contact, high fall risk, scuba, hot yoga
Correct hypoNa too quickly –>?
Central pontine myelinolysis
Tx social anxiety
- Generalized - going to a party, meeting new people
- Performance - public speaking
- SSRI
2. BB or benzo
HIV pt, w/ rapid necrotizing retinitis, painful visual loss cause
HSV
CMV = painLESS, fluffy, granular lesions
1 cause of large bowel obstruction
Neoplasm
Repeated miscarriages with cervical dilation
Cervical incompetence - DES –> adenocarcinoma of vagina
-Cerclage placement
Spinal shock vs. neurogenic shock
Spinal shock = ABSENT bulbocavernosus reflex
It is present in SC damage - neurogenic shock