NBME 9 Flashcards
7 year old boy with 1 month history of urinary incontinence (daytime enuresis) and passage of hard, painful stools. Treatment?
Osmotic laxative; stool accumulates and applies pressure to bladder
-**desmopressin used for constipation 2/2 diabetes insipidus
22 year old woman w/ 2 week history yellowing skin, increasing SOB, scleral icterus, jaundice, increased reticulocytes - Bilirubin, LDH, Alk phos trends
- Hemolytic anemia
- Increased indirect bilirubin - unconjugated bilirubin from lysed RBCs
- increased LDH - lysed RBCs
- normal alk phos
27 year old man hx of schizophrenia on olanzapine brought to ED for episodes of agitation. Given haloperidol which resolved agitation but subsequently was agitated and holding arms rigidly at his side. Treatment?
- diphenhydramine (or benztropine)- anticholinergic med that restores balance in dopaminergic/cholinergic pathways
- *patient having acute dystonic reaction to antipsychotic dopamine antagonists (haloperidol)
Patients with atrial fibrillation should be started on what type of therapy?
Those without afib but with TIA or stroke?
Anticoagulation i.e. warfarin
Aspirin or clopidogrel (anti platelet agents)
47 year old with 12-hour hx spinning sensation that worsens when he closes his eyes. Hearing is normal. Horizontal-rotary nystagmus present. What does he have?
-Vestibular neuritis (inflammation of vestibular portio 8th cranial nerve usually post-infectious)
Menieres disease would present with episodic vertigo, hearing loss, and tinnitus.
Indication for topical mupirocin
Superficial bacterial infections like impetigo
Treatment for candidal diaper rash?
Nystatin
**look for satellite lesions; use of abx= higher risk for development
Juvenile Rheumatoid Arthritis (before age 16)
- Subtypes
- extraarticular manifestations
Oligoarticular disease - fewer than 5 joints and ANA positivity Polyarticular disease - greater than 5 joints, negative ANA Systemic disease (still's disease) - variable joint involvement, rash, quotidian fever, serositis
-Uveitis (slit lamp exam), rash, lymphadenopathy
Management of stable supraventricular tachycardia (regular, narrow complex)
Adenosine (short-active blockade of AV node), vagal maneuvers
- can also use B blockers/CCBs
Indication of Amiodarone
Ventricular and refractory supra ventricular tachycardias
What kind of murmur does Aortic stenosis present with?
Treatment of severe Aortic stenosis
- systolic crescendo-decrescendo murmur with radiation to carotids best heard at upper right sternal border
- Valve replacement
72 yo man w/ PMHx DVT 8 months ago presents with 3 month hx of swelling and discoloration of leg, edema, discomfort.
- Postphlebitic aka post-thrombotic syndrome characterized by venous insufficiency s/p DVT.
- *edema, skin pigmentation, pain, vein dilation, venous ulcer formation weeks to months after DVT
vs. thrombophlebitis= inflammation w/ underlying thrombus, superficial phlebitis= painful, erythematous, palpable thickened cord along affected vein
Initial management of MALT lymphoma
MALT lymphoma due to H. Pylori infection (B lymphocytes stimulated by T Lymphocytes reactive to H. Pylori) –> tx= eradication of H. Pylori therefore:
- Antibiotics - usually resolves condition
- Refractory disease- radiotherapy or immunotherapy (rituximab)
Next step in management for 27 yo woman who has been on PPI at max dose over 6 months for GERD without control of sxs.
24 hour esophageal pH monitoring= gold standard to diagnose GERD and may identify people who have not yet developed esophagitis
- patients that do not respond to PPI may require surgery (Nissen fundiplication)
Lab findings in a man with alcoholic hepatitis which is frequently accompanied by cholestasis
- disproportionate rise in alk phos vs ALT/AST, high bilirubin, and high GGT
Cause of stress incontinence
Cause of urge incontinence
Cause of overflow incontinence
- weakness of pelvic floor muscles – urethral incompetence (loss of support of urethra)
- detrusor instability/overactive bladder (treat with oxybutynin)
- neurogenic bladder; spinal cord injury–> urinary retention and overflow incontinence
Pregnant woman with peritoneal signs 2/2 appendicitis. Management?
Exploratory laparotomy even though she’s pregnant; do not get CT first
Positive predictive value and negative predictive value calculation
Sensitivity and specificity calculation
PPV: true positives/(true positives + false positives)
NPV: true negatives/(true negatives + false negatives)
**horizontal
Sensitivity: True positive/(true positive + false negative)
Specificity: True negative/(true negative + false positive)
**vertical
Tx of BPH in patient with orthostatic hypotension
Finasteride over a1-blocker i.e. tamsulosin) b/c tamsulosin would worsen orthostatic hypotension
- first line is usually a1 blocker
Which nephropathy is associated with HIV, sickle cell disease, and opioid abuse and how is it diagnosed?
FSGS - kidney biopsy
*urine cytology is for urinary tract malignancy
6 year old boy brought in with hair loss and lump on his scalp with concomitant lymphadenopathy- diagnosis?
Tinea capitus– trichophyton tonsurans
Presentation and diagnosis of osteosarcoma
Usually with pain and swelling but can also present with fragility fracture. ** causes bony destruction presenting as cortical/periosteal irregularity and elevation on x-ray
- biopsy of bony lesion necessary for diagnosis (though MRI may precede this)
Woman with abdominal cramps and loose stools/flatulence who eats sugar free gum and diet soda; what is the causative agent?
Sorbitol- can be used as a laxative; osmotic effect b/c poorly absorbed in small bowel
Outcome of untreated childhood umbilical hernia?
Progressive enlargement of umbilical ring
-
Imaging modality for nephrolithiasis
CT scan of abdomen without contrast
Woman with dry skin, nipple discharge, lethargy, no period for 6 months who would like to conceive - what is next step in diagnosis?
TSH- hypothyroidism = common cause of infertility due to increase in prolactin (nipple discharge, anovulatory cycles oligomenorrhea)
Patient s/p Roux en Y with nausea, vomiting, confusion, and following. Which vitamin is deficient?
Thiamine (B1)
- Wernicke Encephalopathy - encephalopathy, gait ataxia, opthalmoplegia - most common in Roux en Y
- Dry Beriberi - symmetrical peripheral neuropathy
- Wet beriberi - high output cardiac failure
Sxs of zinc deficiency
delayed wound healing, loss of taste/smell, acrodermatitis enteropathica *periacral and perioral dermatitis, alopecia, diarrhea
Which of the following is the most important determinant of specificity?
false positives, false negatives, positive tests, negative tests?
False positives
Specificity = 1 - false positive rate
Test is specific if it has a low false positive rate; high specificity rules in diagnosis
Sensitivity = 1 - false negative rate
- sensitive if low false negative rate: can rule out diagnosis
Management of Glioblastoma
- Resection if possible
- Resection not possible–> stereotactic brain biopsy for histologic diagnosis
- Radiation/chemo
What immunizations are necessary in HIV patients?
Influenza, PPSV23 and 13-valent pneumococcal (13 first, then 23 afterwards after some time); Hep B if not immune
Sickle cell patient with acute vaso-occlusive crisis and hypoxia–> tx?
pain management, hydration, and OXYGEN to avoid acute chest syndrome; hydroxyurea can be considered in patients with frequent pain episodes but acute tx as above
Patient with bacterial endocarditis presenting with septic shock–> what kind of antibiotic coverage?
Broad spectrum: gentamicin and vancomycin (cover for MRSA)
Tx of afib w/ RVR
Hemodynamically stable:
Hemodynamically unstable:
Stable: diltiazem, labetalol, or amiodarone (first 2 preferred b/c rate control)
Unstable: synchronized cardioversion
Colon cancer screening for high risk vs. average risk patients?
High risk (1st degree relative with colon cancer)- screening every 5 years starting at 40 or 10 years younger than diagnosis - avg risk- screening starting at age 50 then every 10 years if normal
Lung cancer screening
Low dose CT annually for adults 50-80 with 20 pack year smoking hx that currently smoke or have quit within last 15 years
What vitamins and minerals are commonly deficient in patients with alcohol use disorder?
Vitamins: thiamine, folate, vitamin B12, vitamin B6 (pyridoxine), vitamin A
Minerals: magnesium, iron, zinc
Drugs that lead to SJS
B-lactam antibiotics, sulfa drugs, anti epileptics (carbamazepine), NSAIDs, allopurinol
HOCM murmur/Tx
Systolic murmur increased with valsalva maneuver, standing, hypovolemia
- beta blockers**
Imaging modality best for tamponade
Echo
23 year old woman with 3-year hx intermittent cough productive of copious sputum; severe pneumonia at age 13; x-ray with bronchial thickening- dx?
Bronchiectasis
- irreversible, abnormal dilatation and thickening of bronchi from recurrent necrotizing infections/inflammation
- chronic bronchial obstruction, tobacco use, CF, primary immunodeficiency disorders, kartagener syndrome, allergic bronchopulmonary aspergillosis
Asbestosis presentation
Pulmonary crackles, digital clubbing, signs of pulmonary HTN/RVH- parasternal heave, loud P2, widely split S2
- on x-ray- bilateral infiltrates with lower lung predominance (subpleural densities)
Beryollosis
non-caveating granulomatous with lymphadenopathy similar to sarcoid; aerospace/nuclear engineering
Risk factors for placenta accreta
Previous cesarean deliveries (due to uterine scarring) and placenta previa
Preoperative prophy for total knee replacement
1st/2nd gen cephalosporin (gram positive coverage) - cefazolin
Preoperative prophy for GI surgery
Ciprofloxacin and metronidazole - gram negative/anaerobic coverage
Concern for soft tissue sarcoma- what do you do?
Core-needle biopsy - get biopsy in order to guide management - make a pathologic diagnosis
DKA vs Hyperosmolar hyperglycemic state
DKA- more common in DM1
- low bicarb (<18) and low pH due to acidosis
- ketones in serum/urine due to fatty acid breakdown in liver which become ketones (without insulin)
- hyperglycemia (>250)but not as severe as HHS
- fluids and continuous insulin, monitor K+ (hypokalemia)
HHS- more common DMII
- no ketosis; severe hyperglycemia (>600) and hyperosmolality leading to volume depletion and neurologic complications
- Bicarb>18
- aggressive fluids, electrolyte replacement, insulin
Paraneoplastic syndromes of lung cancers:
Small cell
Squamous cell
Adenocarcinoma
Small cell - cushing syndrome, SIADH, peripheral neuropathy, lambert eaton, subacute cerebellar degeneration
Squamous - Hypercalcemia (PTHrP)
Adenocarcinoma - migratori thrombophlebitis, nonbacterial verrucous endocarditis, hypercoagulability
All - anemia, DIC, eosinophilia, thrombocytosis, acanthosis nigricans
Best imaging for suspected ovarian, tubal, uterine pathology
TVUS
Hot shower exacerbating eye discomfort (blurry vision)
MS- optic neuritis
