Mix1

Question 1

In what condition is pulsus paradoxus typically seen?

Answer 1

cardiac tamponade. During inspiration, increased venous return increases RV volume and causes the IV septum to shift into the LV cavity, reducing LV EDV&raquo_space; decreased stroke volume&raquo_space; decreased BP.

This drop is exaggerated in COPD and asthma due to pooling of blood in pulmonary vasculature&raquo_space; decreased LV preload.

Question 2

Would you have increased or decreased urine sodium in the case of hypovolemia?

Answer 2

Decreased urine sodium. Hypovolemia&raquo_space; decreased renal perfusion&raquo_space; RAS activation. Aldosterone stimulates Na+ reabsorption to sustain blood volume.

Question 3

What is the accepted treatment for pneumocystis jiroveci pneumonia?

Answer 3

TMP-SMX, prednisone if decreased O2 levels.

** TMP-SMX can transiently worsen pneumonia because of the inflammatory effects released by lysed organisms. This is why you’d give corticosteroids in Pt with impaired oxygenation.

Question 4

How does Rx for hospital acquired pneumonia differ from community acquired pneumonia?

Answer 4

HAP = Vanco + Pip-Tazo

CAP = ceftriaxone + azithromycin

Question 5

How do you calculate ideal tidal volume based on weight?

Answer 5

Tidal volume = 6ml/kg of body weight

Question 6

Chronic bronchitis may have a similar presentation to emphysema. How can you tell the difference between the two?

Answer 6

Chronic bronchitis = irritant induced inflammation&raquo_space; hypersecretion of mucus + structural changes of tracheobronchial tree.

Emphysema = destruction of interalveolar walls.

Can tell the difference by:
1. DLCO (measures gas exchange between alveoli and pulmonary capillary blood) is normal in chronic bronchitis (because of intact alveoli) and is decreased in emphysema.

2. CXR in chronic bronchitis = prominent bronchovascular markings + flattened diaphragm. Emphysema shows hyperinflated lungs.
3. Chronic bronchitis has worse emphysema.

Question 7

Hypertrophic cardiomyopathy is an autosomal dominant genetic disorder that involves mutations predominantly in which two genes?

Answer 7

Myosin binding protein C gene, and cardiac beta-myosin heavy chain gene

Question 8

What ECG findings predominate with LVH?

Answer 8

Tall R wave in aVL and deep S wave in V3.

Question 9

What should be the treatment of choice for disseminated histoplasmosis in HIV patients?

Answer 9

Treat infection with amphotericin B (2 wk) and then use oral intraconazole for maintenance therapy (1 yr).

• Itraconazole preferred over fluconazole.

Question 10

What are the 5 components of therapy in preventing/reducing the risk of thrombosis after an NSTEMI?

Answer 10

1. Beta blocker
2. ARB/or Ang II R blocker
3. HMG-CoA R blockers (Statins)
4. Aldosterone antag (spironolactone, eplerenone) in Pt with EF < 40%
5. Dual Antiplatelet Therapy with aspirin and P2y12 R blockers (clopidogrel, prasugrel, and ticagrelor)

Question 11

Asbestosis is a pneumoconiosis resulting from inhalation of particles involved in industrial processes. Progressive dyspnea, clubbing, and end-inspiratory crackles are typical signs. PFT show restrictive lung disease with decreased diffusion lung capacity and normal FEV1/FVC ratio. What are the imaging findings that support this diagnosis?

Answer 11

Typical CXR findings include interstitial abnormalities of lower lung fields and pleural plaques.

Question 12

What is the standard treatment for babesiosis?

Answer 12

7-10 days of atovaquone + azithromycin. OR quinine + clindamycin (for more severe illness)

Question 13

How do you make a Dx of babesiosis?

Answer 13

Babesiosis is typically asymptomatic but can affect immunocompromised/age >50 or asplenic patients. Sx = gradual onset of malaise, fatigue, fever, and chills. Organism multiplies in RBC so you get anemia with intravascular hemolysis (dark urine from Hb, indirect hyperbilirubinemia, reticulocytosis, and elevated LDH and LFTs).

Dx is made by identifying organisms on peripheral blood smear (shows up as maltese cross)

Question 14

Would you typically present with a respiratory alkalosis or respiratory acidosis in an acute asthma attack?

Answer 14

Respiratory alkalosis. You have reactive hyperventilation as a response to hypoxemia/sensation of dyspnea, and signals from thoracic neural receptors influenced by changes in lung volume and presence of inflammatory mediators (prostaglandins, histamine). Hyperventilation&raquo_space; reduced pCO2..

Question 15

What are the potential neuropsychiatric symptoms of hyponatremia?

Answer 15

Patients with significant hyponatremia can develop confusion, lethargy, psychosis, and seizures.

** Potential GI Sx of hyponatremia include ileus, nausea/vomiting, and watery diarrhea

Question 16

What drug can be used for life threatening asthma exacerbation?

Answer 16

IV Mag sulfate

Question 17

What is the standard treatment for acute exacerbation of COPD?

Answer 17

1. Supplemental O2 (target SpO2 of 88-92%)
2. Inhaled bronchodilators
3. Systemic glucocorticoids
4. Oseltamivir (if evidence of influenza)
5. Abx if >2 cardinal sx.

Cardinal sx = increased dyspnea, increased cough (more frequent/severe), sputum production (change in volume/color)

** Treat empirically, no cx necessary. Common abx = macrolides (azithromycin), resp fluoroquinolone (moxi/levofloxi), penicillin/beta lactamase i (amoxicillin-clavulanate)

Question 18

What is the function of roflumilast in maintenance therapy for preventing future COPD exacerbation?

Answer 18

Roflumilast is a phosphodiesterase inhibitor with anti-inflammatory properties that helps decrease mucociliary malfunction and pulmonary remodeling.

Question 19

How doe short term vs long term management of severe hypercalcemia differ?

Answer 19

Hypercalcemia can present as weakness, GI distress, and neuropsych sx (confusion, stupor, coma).

Short term Rx = aggressive saline rehydration and calcitonin to restore intravascular volume and promote urinary calcium excretion.

Long term = bisphosphonates (pamidronate, zoledronic acid). Takes a few days to work.

Question 20

What is the diagnostic test of choice for confirming PE?

Answer 20

CT Angio is the test of choice. Ventilation-perfusion scan can be an alternative for Pt with significant renal impairment, morbid obesity, or contrast allergy. TTE can be used for Pt too unstable for CT angio.

Question 21

What are potential late complications of Hodgkin lymphoma?

Answer 21

Acute or delayed pericardial disease, MI/infarction, restrictive cardiomyopathy, CHF, valvular abnormalities, and conduction defects.

Question 22

What are common causes of glomerular vs nonglomerular hematuria?

Answer 22

Nonglomerular (more common) = cancer (renal cell and prostate), infection (cystitis), BPH, prostatitis, PCKD, and nephrolithiasis. Typically present with dysuria/flank pain/renal colic.

Glomerular = Glomerulonephritis (IgA nephropathy, PSGN), and basement membrane disease (Alport syndrome)

Question 23

What’s the drug of choice for treating infection due to human bite wound?

Answer 23

Amoxicillin-clavulanate because human bite wounds are polymicrobial with aerobic and anaerobic flora. Most common organisms include streptococci, Staph aureus, Eikenella corrodens, H influenzae, and beta-lactamase producing anaerobic bacteria.

Question 24

What are some of the presenting symptoms of pancoast tumors?

Answer 24

Superior sulcus/pancoast tumors are malignant lung neoplasms that present with referred shoulder pain, Horner syndrome, radicular pain, parasthesias, or weakness of ipsilateral arm due to invasion of the brachial plexus (c8-t2)

** Horner syndrome = ipsilateral ptosis, miosis, and anhidrosis from involvement of paravertebral sympathetic chain and inferior cervical ganglion.