NBME 9 Flashcards
s/p transplant MRI shows mass: biopsy shows: proliferation of monocolonal B lymphocytes
Post-transplant lymphoproliferative disorder (PTLD)
in transplant pts on high doses of immunosuppressives
EBV reactivation of virus that evaded T lymphocytes (usually causes mononucleoisis)
tx: decrease immunosuppressives
bone pain, anemia, hypercalcemia, kidney dysfunction, and lytic bone lesions
Multiple Myeloma
**Monoclonal B-lymphocytes **
B-lymphocytes are precursors to plasma cells: neoplastic proliferation of single plasma cells clone: –monoclonal immunoglobulin spike on protein electrophoresis Gamma– M-protein spike
diagnosis confirmed: Bone marrow biopsy with at least 10% plasma cells
2 weeks of jaundice hepatosplenomegaly, hematocrit 20% and reticulocyte 10%
increased: Biliverdin, Indirect Bili, LDH, reticulocytes
hemolysis occuring
either intravascular: release of free hemoglobin into circulation
or
extravascular: within spleen adn reticuloendothelial system through macrophages
erythrocyte turnover lysis:
free hemoglobin broken down –> iron and heme
heme broken down –> biliverdin and indirect bilirubin (increased)
also LDH inside erythrocytes so hemolysis –> increase lDH
hemolysis leads to anemia –> induces bone marrow to increase production of erythrocytes –> making more immature erythrocytes (reticulocytes)
torticollis (head tilted to the side and down), retrocollis (head tilted back), opisthotonos (arching of the back), and oculogyric crisis (deviation of the eyes)
Dystonia
D2 Antagonist: haloperidol, fluphenazine
dopaminergic-cholinergic pathways of the basal ganglia
– Risk factors for development include male sex, young age, recent cocaine use, and hx of previous dystonia.
tx: diphendyramine or benztropine: anticholinergics
should exclude neuroleptic malignant syndrome
Specific phobia criteria:
more than 6 months
distress or social/occupational impairement
anxiety with exposure or anticipation of stimulus
tx: long term CBT
short term benzos
bipolar depression meds:
lamotrigine, quetiapine, lurasidone
lithium carbonate
If pt previously taking med – just restart them on previous meds (if they stopped for no reason)
emotional !ability, disinhibition, sedation, slurred speech, and ataxia, normally reactive pupils
chronic: slow respirations, hypoglycemia and ketoacidosis
alcohol intoxication
malnutrtion
(also called ethanol)
tx: repleating vitamins and electrolytes, IV fluids, supportive
can lead to coma so intubation
floppy baby
dx?
Botulism: NMJ clostridium botulinism
gram positive spore-forming obligate anaerobe
cleaves SNARE proteins preventing release of Acetylcholine
infants: raw honey, canned foods, pork, or SOIL DUST SPORES inhale
dx: reptitive nerve stimulation study electromyography (improves with stimulation
tx: immunoglobulin, supportive care, mechanical ventilation
pt with afib has storke
what would prevent a stroke?
anticoagulation: WARFARIN
w/ recent use of antibiotics ear infection
candidiasis
diaper rash
red macerated thin plaques with satellite papules – vs dermatitis
oral: thick white plaques on the tongue or buccal mucosa that can be scraped off with a tongue blade
risk factor: recent use of antibitiocs
tx : topical nystatin
comedomal and papular acne
tx
first line: mild/mod acne
topical retinoid
apply over entire involved area to prevent new comedones instead of spot treatment on existing lesions
septic arthritis
painful swollen right telbow with fever
STAPH AUERUES
under age 16: joint pain
can also have: uveitis, lymphadenopathy, rash
positive ANA
negative RH
Juvenile rheumatoid(idiopathic) arthritis
oligoarticular disease: few than five joints (usually knee) + ANA positive
polyarticular: more than five joints (interphalangeal joints) + nevative ANA
UVIETITIS
so do slit lamb examination
tx; NSAIDS, methotrexate
uveitis: cataract surgery
tumor in metacarpals and fingers, painless
multiple in one extremity
multiple with soft tissue angiomas
enchodroma
Ollier disease
Maffucci syndrome
observation benign
spiculated lung lesion + fractured femur with radiolucent defect with focal breaching of cortex laterally
adenocarcinoma
metastasis (spiculation) to bone
right groin pain, flexion and extension limited ROM, xray: lytic and sclerotic lesions of femoral head
osteonecrosis
avascular necrosis
painful degeneration
associted with alcohol use, fractures/dislocation, corticosteroids use, sickle cell disease, bisphophonates, gaucher disease
idiopathic osteonecrosis: Legg-calve perthes: children 4-10
gold standard dx: MRI
tx: surgery and PT
chronic venous insufficiency
reddish-brown hyperpigmentation below the knee
post-phlebitic syndrome post-thrombotic syndrome
occurs usually after DVT
new head, neck, mandibular angle mass
greater than 2 weeks
fixed mobility
firm texture
hx of prior cancer or immunocompromised
next step?
Fine needle aspiration to see if its cancer
urethral hypermobility
cottin tipped applicator with greater than 30 degrees deviation
stress incontinece
Si also caused by urethrocele or cystocele
appendicitis symtpoms in pt who is prego
next step?
ex lap
usually would need to do CT but since shes prego you cant
chronic dysmenorrhea, dyspareunia, dyschezia, and infertility
that are with the hormonal cycle
u/s homogenous internal echoes
Endometriosis
endometrial glands and stroma outside of the uterus
Subsequent fibrosis can cause palpable nodularity of the posterior uterus and cul-de-sac along with fixation of the uterus to nearby structures making it immobile
gold-standard for the diagnosis of endometriosis is a diagnostic laparoscopy
vs leiomyomma myoma fibroids – will see solid mass on u/s
diabetic neuropathy foot ulcer
Screening for neuropathy is performed yearly using a monofilament test.
prevention: wear protetctive shoes when moving standing or walking (because they wont notice if they injure themselves)
a metric of overall disease burden, which takes into account not only the years of life lost because of death but also the years of healthy life lost as a result of disability, thus incorporating morbidity and mortality into one metric.
disability-adjusted life years DALY
vs
Years of potential life lost (YPLL) would take into account the increased mortality rate that accompanied the change in legislation but not the impact of increased morbidity in nonlethal traumas.
motorcycle wearing helmet or not
pap smear shows atypical glandular cells
next step?
colposcopy with endocervical curettage
also in age older than 35: endometrial biopsy recommended
Cytologic study of cells collected from the cervix is recommended every 3 years in women aged 21 to 29 years
every 5 years in conjunction with human papillomavirus co-testing (every 3 years if co- testing is not performed) in women aged 30 to 65 years.
cervical intraepithelial neoplasia on cytological study from cervix
next step?
cone biopsy of cervix
(can cause cervical stenosis)
milky chest tube drainage with pleural effusion in newborn
chylothorax
d/t injurty to thoracic duct (trauma during delivery) allows chyle to add up in pleural space
or
congential: hydrops fetalis, downs, turners, noonan
tx: chest tube and oxygen
2-4 weeks of diarrhea, bloating, weight loss after traveling abroad
giardia
ingestion of cysts in water – hand hygiene – untreated waer
usually self limited in 1-2 weeks
for more than that:
dx: stool culture, microscopy, stool antigen testing
tx: oral metronidazole or tinidazole
immobile breast mass with spiculated margins and microcalicfication
invasive ductal cacrinoma
tumor staging with lympoh node involvement #1
Negative prognostic factors include age with both young and elderly patients having higher mortality, African American race, higher tumor stage (including nodal involvement and tumor size) or
histologic grade, and HER2 gene expression, whereas estrogen-receptor and progesterone-receptor expression are associated with
improved outcomes.
BPH in pt with orthostatic hypotension
usually would give -osin alpha blocker
but since othrohypotension
only finasteride 5 alpha reductase
hyperaldosteronism
next step
spironolactone
usually due to adrenal adenoma
or b/l adrenal hyperplasai\ia
pt with systemic scleroderma and has non healing ulcer on toe for over one month
next step?
since has scleroderma – wont let it heal properly – turns into osteomyelitis
next step: amputation
migraine prophylaxis
lipophilic 13-adrenergic blocking drugs that cross the blood-brain barrier (eg, propranolol, metoprolol), antidepressants such as tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors, and anticonvulsants such as topiramate or valproate.
aucte: triptans (serotonin 1b/1d agonist) and ergotamine but chornic use can cause migraines too
proteinuria4+ + sickle cell disease, opioid abuse, and HIV infection,
FSGS
dx: must do renal biopsy
tx: steroids or immunomodulators
yearly DM (glucose) testing for
ages 40-70 who are overweight
SCID tx
bone marrow transplant
vs
agammaglobinemia (burtons) btk IVIG
red streak tender from wrist to elbow
lymphangitis
A streptococci, Staphylococcusaureus, Pasteurella multocida, Bartone/la henselae, or Sporothrix schenckii
dx: microspocopy and culture swab
sensorineural hearing loss + vertigo sxms
tx
meniere’s
pressure accumulation in endolymph of inner eat
triad: episodic vertigo, hearing loss, and tinnitus.
tx: lifestyle modificaitons: avoidance of salt, nicotine, alcohol, or stress
antihistaminic meds: meclizine promethazine for the vertigo and nausea
15yo Boy with painful lump on right thigh
An x-ray of the right femur and knee shows evidence of bone destruction with irregular, ragged, radiolucent defects and new bone formation
osteosarcoma
primary bone cancer in children
cells with enlarged nuclei and a disorganized tissue structure that demonstrates areas of osteoid production (mineralized collagen that provides the structure of bone)
malignancy is locally destructive to bone and can erode through the cortex resulting in a periosteal reaction with elevation of the periosteum along with irregular, ragged borders and areas of disorganized osteogenesis as seen in this case.
metastasis usually to LUNGS
dx: imaging MRI and open biopsy of bone lesion
tx: surgical resection with chemotherapy
JVD that increases with inspiration
Kussmaul sign – constrictive pericarditits
better with leaning forward
tx: supportive with Colchicine + NSAIDS (ibuprofen)
ruptured aortic aneurysm risk:
Smoking
COPD managment
daily inhaled long acting bronchodilator (b-agonist: salmeterol or muscarinic antagonist: tiotropium)
and inhaled glucocorticoid fluticasone
supplemental oxygen to keep range of 88-92%
SABA/SAMA + abx + systemic corticosteroids
umbilical hernia in children
spontaneous resoltion by age 3
if not: progressive enlargement of the umbilical ring
if older than 3, or defects > 1.5cm
benzodiazepine overdose tx
flumazenil
kidney stones
next step in dx
CT scan without contrast
u/s is less sensitive
if calcium oxalate: thiazide diuretics, a low-sodium diet, and supplementation with potassium citrate
lithiotripsy next step if larger
postpartum pt with fever and uterine tenderness
endometritis
tx: IV antibiotics (clindamycin or gentamycin)
diffuse macular rash
vs
diffuse petechial rash
toxic shock syndrome
vs
meningococcemia
glioblastoma in adults: rim-enhancing, intra-axial masses commonly corss midline
mangtm:
stereotactic brain biopsy
posterior circulation stroke (cerebral infarct)
vertebral arteriest
ipsilateral: cranial nerve dysfxn dysphagia, dysarthria
contralateral hemiparesis: corticospinal tract damage
contralateral impairement in pain and temp (spinothalamic)
or potential contralateral homonymous hemianopsia with macular sparing
if lateral pons affected: horner syndrome: ipsilateral ptosis, miosis, anhydrosis
bilateral loss of pain and temperature sensation and motor function below the level of the lesion, along with autonomic dysfunction.
anterior spinal artery
medial frontal and parietal lobes (primary motor and sensory cortices), which control the motor and sensory function of the lower extremities.
contralateral hemiparesis and sensory deficit of the lower extremities.
anterior cerebral artery
right homonymous hemianopia with macular sparing and Gerstmann syndrome (agraphia, acalculia, finger agnosia, and left-right disorientation)
left posterior parietal and occipital lobes along with the thalamus and midbrain
left posterior cerbral artery
greatest risk for development of dementia
advancing age
amyloid ad tau protein
baby with asymetric thigh skinfolds and palpable clunk hip
developmental dyspasia of hip
dx with ultrasounds of hip
tx: reduction of the femoral head in the acetabulum, either by closed reduction and immobilization in a harness or spica casting, or open reduction under general anesthesia.
pt with gagging and inability to feed with oral secretions
esophageal atresia with TEF
dx: insertion of nasogastric tube
confirm with esophagrogaphy with contrast
tx: surgery
additional screening for Vertebral, Anal, Cardiac, Tracheal, Esophageal, Kidney, Limbs
and
Coloboma of eye, Heart Anomaly, Choanal aTRESIA, rETARDATION, Gential and ear anomalies
diarrhea from food poisoing, bright red blood in poop
just came from trip in mexico
campylobacter jejui
comma shaped
self limiting
can caused reactive artitstis in pts with HLA b27 and Guillaine barre syndrome
you dont need abx
hyperglycemia and hyperosmolality >320
nonketotic hyperosmolar state
tx: IV normal saline
agitation bruxism, diaphoresis, htn tachycardia, hyperthermia (fever) thirsty
ecstasy
high b-hcg with no gestational sac
ectopic pregnancy
tx: methotrexate for small early pregos
mary require salpinectomy or evacuation with laparoscopy for larger pregnancies
vs hydatidform mole
bilateral multilocular ovarian cysts (theca lutein cysts)
and abnormal echogenicity in the uterus.
albinism, peripheral neuropathy, recurrent pyogenic infections
impaired chemotaxis of neutrophils
chediak higashi
HIV what vaccines
Influenza virus, 23-valent pneumococcal, hepB, meningococcal
pcv13 first, 8 weeks later PPSV23
drug for nausea and gastroparesis taht can cause Parkinson symptoms
metoclopramide D-2 antagonist
pts with NF2 need what annual screening
encodes merlin schwannomin
b/l acoustic schwannomas, cataracts, meningiomas, ependymomas , schwannomas
monitor for exsiting tumors and new ones
annual audiometry
annual **brain MRI at age 10
HAND FOOD mouth disease
mgt:
observation only
pertussis mgnt
macrolides and supportive care
prevented with tdap vaccine
booster every 10 years
waning vaccine immunology
drowning can result :
ARDS
ischemic damage – cerebral edema
intubate them
purposeful movements is good sign
pt with ascites and unconcsious
magt:
measurement of cell count and differential of abdominal fluid
SBP (HIGH LEUKOCYTES)
tx with cefTRIaxone
scuba diving come up too fast
decompression sickness
tx: Iv hydration, 100% O2,, hyperbaric therapy
painless lumb on side of neck, with supraclavicular lymph node rubbery firm, splenomegaly
increased LDH and ESR
hodgkin lymphoma
xanthelasma
check Lipid levels
may need to start on statins
no tx
child recovering from recent viral infection now has pain at hip, flexed/externally rotated
xray negative
transiet synovitis at hiop
elevated ESR inflammatory marker
tx: supportive
rule out septic arthritis, osteomyelitis, fracture
renal artery stenosis mgt:
dx:
tx:
abdominal bruit
fribomuscular dyspalsia in younger
renal vein sampling would show increased renin on atrophied affected side
dx: MR-A or renal doppler ultrasonography
tx: angioplasty or stenting of stenosed renal artery to improve flow
ace inhibitors for unilateral stenosis but can lead to acute kidney failure in setting of b/l renal artery stenosis
iga deficiency
anaphylactic after blood transfusion
what next?
epinephrine
alcohol use disorder : what vitamin deficiency
thiamine, folate, vitamin B12, vitamin A, and vitamin B6, while commonly deficient minerals include magnesium, iron, and zinc.
Stevens-Johnson syndrome (SJS) is a severe cutaneous drug reaction that can easily progress to
toxic epidermal necrolysis
<10% for SJS and >30% for TEN
Unlike the management of burn patients, however, debridement or any accidental removal of sloughing epidermis must be avoided as this greatly increases the risk of infection
intensive support and wound management in burn unit
NSAIDS on kidneys
can impair renal function
Nonsteroidal anti-inflammatory drugs decrease the production of prostaglandins by inhibiting cyclooxygenase. High doses or prolonged use of these drugs may cause decreased glomerular perfusion by** reducing afferent arteriolar vasodilation**, leading to acute or chronic kidney damage.
worsening severe chest pain, previously resolved with rest but now longer in duration and worsening pain severity
what next?
initially stable angina resolved with rest
but now that theire is an increase : unstable angina
needs to be admitted to hospital for further ACS workup: serial ecgs, troponin, and theeeeen stress test or cardiac catheteriszation
pt with (38yo) brisk carotid upstroke, systolic murmur at left sternal border, worsening murmur with valsalva and with standing, ecg shows LV hypertrophy
meds?
HOCM
can cause LVOT
tx: b-blockers slow the pulse and reduce likelihood of ectopic beats
nifedipine (ccblockers)
nose bleeds
hereditary hemorrhagic telangiectasia
formations of telengiectasia and av-malformations
child
exercise intolerance caused by failure to supply exercising lower extremity musculature with increased blood flow, atrophic lower extremities, diminished pulses in the lower extremities, a differential in blood pressure when measured between the four extremities, a systolic murmur (in this case, an epigastric bruit), and left ventricular hypertrophy on ECG.
coarctation of aorta
CT
or MR-A
or arterial doppler
or echo
77yo painless mass on right earlobe started increasing in size, firm, irrefular, nontender angle of mandible
next step
fine-needle aspiration
gets sick, then indirect bili goes up
gilbers
glucuronyltransferase enzyme reduction
calcifications and pancreatic duct obstruction with foul smelling diarrhea and upper abdominal pain that radiates to back
chronic pancreatitis
give prancreatic enzyme supplementation
pancreatic insufficiency as a result of chronic, progressive pancreatic inflammation, fibrosis, and loss of acinar cells and islet cells.
not pancreatic cancer
CT scan of the abdomen with contrast shows a 2.5-cm enhancing cystic mass lesion with internal necrosis in the mid pole of the left kidney.
next step?
RENAL cell carcinoma
left nephrectomy
an enhancing mass lesion with central necrosis
Lesions with central necrosis, a size larger than 4 to 5 cm, or clinical findings such as hematuria should raise the suspicion for RCC.
Arrest of active labor occurs when there is no cervical change for greater than 4 hours with adequate contractions or greater than 6 hours with inadequate contractions.
a result of cephalopelvic disproportion or a non- occipitoanterior fetal presentation. If the fetal head is fully engaged in the pelvis, management can include operative vaginal delivery; if it is not, cesarean delivery is recommended.
placenta previa or prior c/s can cause:
placenta accreta
risk of postpartum hemorrhage
fish like odor, vaginal pH> 4.5
gray thin malodorous d/c
garnerella vaginalis
Bacterial Vaginalis
must do KOH wet mount prepartion
and then metronidazole
cushing:
measurement of 24-hour urine free cortisol,
late night salivary cortisol concentration, (not 8am which is used for adrenal insufficiency)
or the use of the overnight dexamethasone suppression test.
focal white infiltrates patchy on eye
candidal ophthalmitis
2/2 central line placement, hemodialysis or abscess
Multiple scleoris fatigue
heat sensitivity so avoid outdoor activities in the heat
cooling technicques: cold drinks, lightweight clothing, air conditioning, ice packs, cooling suits) may improve heat-related exacerbations. Lifestyle modifications that apply to all patients such as maintaining a balanced diet, regular exercise, and avoiding excessive alcohol use are also recommended for MS patients to reduce neuroinflammation.
light pink, ill-defined macules with a gritty texture in areas of prolonged sun exposure, such as the face, ears, and dorsal hands.
actinic keratosis
hyperkeratotic, crusted papules, plaques, or nodules, which may be ulcerated
squamous cell carcinoma
prophylaxis perioperative antibiotics ahead of surgeries like total knee replacement:
cephalosporins like parenteral cefazolin
to cover skin infections like staph or strep
tumor in leg: increasing size, lack of pain, and firmness.
xray neg
mri: soft tissue mass
concern for malignancy so do a core needle biopsy soft tissue sarcoma
pt with urinary catheter for urinary incontinence and has alzheimers
what would have prevented infection
Urinary catheters are typically not indicated for long term use in patients with urinary incontinence, and these patients should be switched to the use of absorbent pads.
use of incontinence briefs
coombs positive vs negative in pt with blood transfusion
positive: means ABO incompatibility life threatneing (acute hemolytic transfusion reaction)
negative: febrile transfusion reaction (preformed antibodies to donor leukocyties and/or cytokines in the plasma)
