random

Question 0

Heberden and Bouchard nodes

Answer 0

• can be cause by severe osteoarthritis

- hard, bony nodules over the distal (Heberden) and proximal (Bouchard) interphalangeal joints, respectively

Question 1

rheumatoid nodules

Answer 1

• firm, flesh-colored and NONTENDER
• typically occur over pressure points such as the elbow and extensor surface of the proximal ulna
• almost all these pts will have positive rheumatoid factor levels

Question 2

“sausage digit”

Answer 2

-severe PSORIATIC arthritis typically first affects the distal interphalangeal joints and clinically manifests as a “sausage digit”, where the digit takes on a swollen fusiform shape w/ significant hyperemia

Question 3

Chronic tophaceous gout

Answer 3

• urate crystals can be deposited in the skin resulting in the formation of tumors (tophi) w/ a chalky white appearance
• be on the lookout for the great toe being affected (podagra) w/ monosodium urate crystals
• Uric acid crystals form in the renal tubules and collecting system resulting in NEPHROLITHIASIS
• Ddx includes rheumatoid nodules and calcinosis cutis when suspected tophi are seen
• Note that diuretics in general have a hyperuricemic effect resulting from hypovolemia-associated enhancement of uric acid reabsorption in the proximal tubule

Question 4

myocardial contusion

Answer 4

• tachycardia, new bundle branch blocks or arrhythmia

- sternal fracture is commonly associated injury

Question 5

myocardial rupture

Answer 5

• cardiac tamponade (muffled heart sounds, hypotension, distended neck veins)
• diagnosis is made rapidly w/ US

Question 6

esophageal rupture

Answer 6

• rare following blunt trauma
• Iatrogenic (ie w/ endoscopy) and esophagitis-related etiologies are more common
• may have pneumomediastinum and PLEURAL EFFUSIONS

Question 7

Diaphragmatic rupture

Answer 7

• abdominal pain, pain referred to the shoulder, shortness of breath, and/or vomiting
• CXR may show abdominal viscera above the diaphragm, and/or loss of the diaphragmatic contour

Question 8

Hemothorax

Answer 8

• may result from injuries to the aorta, myocardium, hilar blood vessels or lung parenchyma
• symptoms depend on degree of blood loss and can range from SOB to shock

Question 9

Pts sustaining rapid deceleration injuries to the chest require radiographic evaluation for aortic injury w/ x-ray, CT scan and possibly TEE as well

Answer 9

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Question 10

Persistent pneumothorax and significant air leak following chest tube placement in a patient who has sustained blunt chest trauma suggests what?

Answer 10

• Tracheobronchial rupture

- other findings include pneumomediastinum and subcutaneous emphysema

Question 11

rash associated w/ secondary syphilis

Answer 11

• generalized maculopapular lesions involving the trunk and extremities w/ associated lymphadenopathy
• rash typically does NOT spare the palms and soles

Question 12

Disseminated gonococcal infection

Answer 12

• causes high fever, chills, tenosynovitis, polyarthralgia, and pustular lesions on the trunk and extremities
• should be considered when risk factors for gonococcal infection are present
• routine blood and pustule cultures can be negative due to the fastidious nature of Neisseria gonorrhoeae
• may also have migratory asymmetric polyarthralgia without purulent arthritis (wrists, ankles, fingers, and knees)
• recurrent DGI: check terminal complement activity
• treat for chlamydia empirically w/ azithromycin or doxycycline
• treat gonorrhea w/ IV ceftriaxone

Question 13

Osteoarthritis

Answer 13

• non-inflammatory arthritis presenting with pain that is worse w/ activity and improved w/ rest
• x-ray findings include joint space narrowing and osteophytes, and subchondral sclerosis/cysts.
• synovial fluid analysis will reveal fewer than 2000 WBC/ml, no organisms, and no crystals
• most commonly affects hands and weight-bearing joints
• increasing age is leading risk factor
• typically have mild morning stiffness (

Question 14

Punched out erosions w/ a rim of cortical bone

Answer 14

• characteristic x-ray findings in gouty arthritis
• acute joint pain and synovial fluid shows WBC count 2000-50,000/mL and NEEDLE-SHAPED, NEGATIVELY birefringent crystals (yellow when parallel)

Question 15

periarticular osteopenia and joint margin erosions

Answer 15

• classic for rheumatoid arthritis (RA)
• inflammatory arthritis presenting w/ morning stiffness ( >30 minutes) and systemic symptoms of fever, malaise, and weight loss
• WBC count of synovial fluid is 2,000-50,000/mL
• wrists, MCP and PIP joints are commonly involved
• the joints will be warm to the touch

Question 16

normal joint space w/ soft tissue swelling

Answer 16

• infectious arthritis

- cell count of > 50,000/mL is typical on synovial fluid and gram stain is often positive

Question 17

calcification of cartilaginous structures

Answer 17

• CHONDROCALCINOSIS
• typical of pseudogout, or calcium pyrophosphate dihydrate (CPPD) deposition
• acute swelling, stiffness, and pain of the knee after surgery or medical illness
• synovial fluid = 2,000 - 50,000mL w/ RHOMBOID, POSITIVELY birefringent crystals (blue when parallel)

Question 18

Ankylosing spondylitis

Answer 18

• pts can develop restrictive lung disease due to diminished chest wall and spinal mobility
• PFTs show a mildly restrictive pattern w/ reduced vital capacity and total lung capacity but normal FEV1/FVC
• low back pain (age of onset

Question 19

obstructive lung disease patten on PFTs

Answer 19

-FEV1:

Question 20

Restrictive lung disease (including obesity) pattern on PFTs

Answer 20

• FEV1: 70%

- FVC:

Question 21

Rotator cuff tear

Answer 21

• may result from trauma (eg falling on an outstretched arm) or as the end result of chronic impingement and tendonitis
• similar to pts w/ rotator cuff tendinitis, pts often complain of pain upon reaching and lifting the arm over head. However, weakness of the shoulder is more common in rotator cuff tears, and symptoms do not improve w/ lidocaine injection

Question 22

Adhesive capsulitis

Answer 22

• aka “frozen shoulder”
• idiopathic condition characterized by pain and contracture
• inability to lift the arm above the head due to fibrosis of the shoulder capsule

Question 23

Cervical radiculopathy

Answer 23

• typically presents w/ pain of the neck and arm
• paresthesias of the arm are present in 80% of pts
• weakness may affect the shoulder, elbow, or wrist
• movement at the neck exacerbates symptoms

Question 24

thoracic outlet syndrome

Answer 24

- combination of numbness, weakness and swelling due to compression of the subclavian vessels and lower trunk of the brachial plexus - a weakened radial pulse and reproduction of symptoms w/ specific arm movements supports the diagnosis

Question 25

Rotator cuff tendonitis

Answer 25

- usually caused by impingement and is most common in middle-aged and older pts who perform repetitive arm movements above the head - presents w/ pain when lifting the arm - may be differentiated from rotator cuff tear and frozen shoulder by injection of the joint w/ lidocaine - in the case of isolated rotator cuff tendonitis, any pain and limitation of motion is resolved by the injection

Question 26

who may be rheumatoid factor positive?

Answer 26

-pts w/ rheumatoid arthritis, SLE, Sjogren syndrome, dermatomyositis, HCV infection and others

Question 27

Antimitochondrial antibodies is associated w/ what?

Answer 27

Primary biliary cirrhosis

Question 28

Anti-neutrophil cytoplasmic antibodies

Answer 28

-granulomatosis w/ polyangiitis (Wegener's)

Question 29

Anti-smooth muscle antibodies

Answer 29

-autoimmune hepatitis

Question 30

anti-topoisomerase-1 antibodies

Answer 30

systemic sclerosis

Question 31

Systemic sclerosis

Answer 31

- form of scleroderma w/ widespread organ involvement - GERD, right heart failure, and hypertension result from involvement of the esophagus, pulmonary arteries and kidneys, respectively. - antinuclear autoantibodies and anti-topoisomerase-1 antibodies would most likely be present

Question 32

Pseudogout

Answer 32

- cannot be reliably distinguished from gout and septic arthritis based on history and physical alone - diagnosed by the presence of RHOMBOID, POSITIVELY birefringent crystals on synovial fluid analysis, and radiographic evidence of CHONDROCALCINOSIS - acute form of calcium pyrophosphate dihydrate (CPPD) crystal disease - frequently precipitated by trauma, surgery, or medical illness - knee is most commonly affected joint

Question 33

gout

Answer 33

- monosodium urate crystals | - needle-shaped and NEGATIVELY birefringent on synovial fluid analysis

Question 34

most common crystal found in renal calculi?

Answer 34

calcium oxalate

Question 35

type of renal calculi found in pts w/ UTI caused by urease-producing organisms (Klebsiella, Proteus)?

Answer 35

Struvite (magnesium ammonium phosphate)

Question 36

Initial disease-modifying antirheumatic drug of choice in pts w/ rheumatoid arthritis? side effects?

Answer 36

- Methotrexate - side effects: GI symptoms, oral ulcers or stomatitis, rash, alopecia, hepatotoxicity, pulmonary toxicity, and bone marrow suppression - FOLIC ACID supplementation has been shown to reduce the incidence of adverse effects of MTX therapy w/o loss of efficacy

Question 37

Anti-cytokine agents used for treatment of rheumatoid arthritis?

Answer 37

- TNF-a inhibitors (etanercept, infliximab, adalimumab), IL-1 receptor antagonists (anakinra, canakinumab), and IL-6 receptor antagonists (tocilizumab) - these agents are generally reserved for use in pts resistant to intitial DMARD therapy - TNF-a inhibitors can cause neutropenia, infections (reactivation of latent TB, opportunists), exacerbations of heart failure, demyelinating illness, and increased risk of malignancy

Question 38

Side effects of chronic glucocorticoid use?

Answer 38

-weight gain, HTN, peptic ulcer disease, glucose intolerance, myopathy, osteoporosis, increased risk of infections

Question 39

Felty syndrome

Answer 39

-clinical disorder seen in pts w/ severe, long-standing (>10 yrs) RA that is characterized by neutropenia and splenomegaly.

Question 40

Pts w/ RA have an approx. 2-fold increase risk of lymphoma, which may present w/ low-grade fever, fatigue, and a palpable spleen

Answer 40

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Question 41

Polymyalgia rheumatica (PMR)

Answer 41

- age > 50 - subacute to chronic (>1 month) pain in the shoulder and hip girdles - morning STIFFNESS lasting > 1 hour - constitutional symptoms - elevated ESR (> 40) - no other apparent explanation of symptoms - Tx: low-dose prednisone (if uncomplicated), which should result in rapid relief of symptoms

Question 42

Fibromyalgia

Answer 42

- most commonly presents in young to middle-aged women w/ widespread pain, fatigue, and cognitive/mood disturbances - pts have point muscle tenderness in areas such as the mid trapezius, lateral epicondyle, costochondral junction in the chest, and greater trochanter - regular aerobic exercise and good sleep hygiene are recommended

Question 43

NSAIDS are occasionally useful in polymyalgia rheumatica for mild breakthrough discomfort or minor relapse of symptoms while tapering glucocorticoids. However, they are much less effective than glucocorticoids for initial management and are not recommended.

Answer 43

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Question 44

what are you concerned about in a chronically wounded, scarred or inflamed skin over time? what is the eponym?

Answer 44

- Squamous cell carcinoma - malignancy should be suspected in all non-healing wounds - SCC arising within burn wounds is known as a MARJOLIN ULCER - SCC has also been described arising in the skin overlying a focus of osteomyelitis, radiotherapy scars and venous ulcers; these types tend to be more aggressive - a biopsy should be obtained in all chronic wounds failing to heal in order to rule out malignancy

Question 45

When a wound fails to heal after a prolonged period, biopsies should be obtained to ensure the ulcer has not degenerated into a squamous cell carcinoma. When SCC arises within a burn wound, these ulcers are known as what?

Answer 45

Marjolin ulcers

Question 46

Melanoma

Answer 46

-typically occurs in pts w/ a nevus that has increased in size, changed color, become palpable or become symptomatic (painful, pruritic, or bleeding)

Question 47

Basal cell carcinoma

Answer 47

- classically presents on chronically sun-exposed skin | - lesions are usually pearly telangiectatic papules w/ a central "rodent" ulceration

Question 48

Dysplastic nevi

Answer 48

- melonocytic nevi exhibiting characteristics not seen in standard nevomelanocytic nevi - size greater than 6 mm, irregular borders, irregular pigmentation - varying degrees of architectural disorders and cytologic atypia

Question 49

precursor lesion to squamous cell carcinoma?

Answer 49

Actinic keratosis (common on chronically sun-exposed skin)

Question 50

Polymyositis

Answer 50

- idiopathic inflammatory muscle disease - slowly progressive PAINLESS, PROXIMAL WEAKNESS of the LOWER EXTREMITIES characterized by difficulty ascending and descending stairs or rising from a seated position; proximal arm weakness usually follows, leading to difficulty combing hair or working w/ the hands overhead - pts may develop dysphagia due to involvement of the striated muscles of the upper pharynx - there are NO skin findings in PM, distinguishing it from dermatomyositis - a MUSCLE BIOPSY is the best diagnostic test and typically shows a mononuclear infiltrate surrounding necrotic and regenerating muscle fibers

Question 51

Myasthenia gravis

Answer 51

- muscle weakness and fatigability - cranial nerve and proximal limb weakness that worsens w/ repeated activity and resolves w/ rest - symptoms resolve rapidly w/ administration of edrophonium (anticholinesterase test)

Question 52

Electroencephalography (EEG)

Answer 52

-used primarily in the evaluation of pts w/ seizure or sleep disorders

Question 53

Lumbar puncture

Answer 53

-useful to evaluate weakness in cases of suspected Guillain-Barre syndrome (ascending weakness w/ paresthesias and autonomic disturbances) or multiple sclerosis (episodic optic neuritis or transverse myelitis)

Question 54

Hyperkalemia is a possible complication of ACE inhibitor (eg lisinopril) therapy and may present w/ flaccid paralysis. However, uncommon in pts w/o underlying renal insufficiency or additional meds that cause hyperkalemia

Answer 54

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Question 55

Giant cell arteritis

Answer 55

- a temporal artery biopsy is necessary to make the diagnosis - usually presents w/ headache, jaw claudication, and systemic symptoms - commonly associated w/ polymyalgia rheumatica, which causes diffuse PAIN in the shoulders and hips but NOT WEAKNESS

Question 56

Tension pneumothorax

Answer 56

- emergency situation and needs immediate needle thoracostomy based on clinical diagnosis (no imaging needed!) - placement of subclavian central venous catheters accounts for approx. 1/4 of iatrogenic pneumothorax - clinically characterized by rapid onset severe SOB, tachycardia, tachypnea, hypotension, and distention of the neck veins due to SVC compression - tx: immediate needle thoracostomy to decompress pleural cavity, followed by an emergency tube thoracostomy w/ underwater seal

Question 57

Cardiac tamponade

Answer 57

- hypotension, tachycardia, elevated systemic venous pressure and pulsus paradoxus - pericardiocentesis is indicated

Question 58

Mild traumatic brain injury (TBI) management

Answer 58

- pts w/ mild TBI w/ repeated vomiting, headache, or LOC should undergo head CT scan without contrast or observation for 4-6 hours - if head CT scan is normal or the observation period is uneventful, pt can be discharged home w/ a reliable guardian; detailed return precautions should also be provided - Mild TBI: GCS 13-15, LOC

Question 59

serious TBI

Answer 59

- GCS 5 min, neuro deficit, signs of basilar skull fracture - require neuroimaging w/ non-contrast head CT, close inpatient monitoring w/ neuro checks q2 hrs, and a neurosurgery consult

Question 60

Minor head trauma

Answer 60

- GCS of 15, normal mental status, no abnormal neuro or funduscopic findings, and no evidence of skull fracture - do NOT require neuroimaging or hospitalization

Question 61

why order non-contrast head CT in trauma?

Answer 61

because contrast looks like an acute bleed, thus distinguishing them more difficult

Question 62

Sjogren syndrome

Answer 62

- diagnosed when subjective or objective evidence of dry eyes and mouth exists in the presence of either histologic evidence of lymphocytic infiltration of the salivary glands or serum autoantibodies against SSA (Ro) and / or SSB (La). - autoimmune condition that most commonly affects women in their fifth and sixth decade - keratoconjunctivitis sicca (xerophthalmia, dry eyes) and xerostomia (dry mouth); increased incidence of dental caries; difficulty swallowing

Question 63

Antimitochondrial antibodies

Answer 63

-associated w/ Primary Biliary Cirrhosis (PBC), an autoimmune disease characterized by progressive jaundice, varices, and other signs of cirrhosis

Question 64

Barium swallow test

Answer 64

-used to assess disease of esophageal motility such as achalasia or presence of esophageal diverticulum

Question 65

test to diagnose Barrett esophagus

Answer 65

- esophageal endoscopy w/ biopsy | - Barrett's: metaplasia of squamous epithelium to columnar epithelium and is a precursor of esophageal adenocarcinoma

Question 66

what is the most common cause of lower extremity edema?

Answer 66

- Venous insufficiency (valvular incompetence) | - classically worsens throughout the day and resolves overnight when the patient is recumbent

Question 67

how does edema caused by lymphatic obstruction present?

Answer 67

- uncommon cause of edema - may result from malignant obstruction of lymph nodes, lymph node resection, trauma, and filariasis - classically affects the DORSA OF THE FEET and causes MARKED THICKENING and RIGIDITY of the skin

Question 68

signs of arterial occlusion in extremity?

Answer 68

pain, pallor, paresthesias, pulselessness, and coolness to the touch

Question 69

Rotator cuff tears

Answer 69

- result from chronic rotator cuff tendonitis and shoulder trauma - shoulder pain and weakness when lifting the arm above the head (or mid arc abduction, external rotation) is suggestive of rotator cuff pathology - a lidocaine injection ameliorates the pain and weakness of rotator cuff TENDONITIS, while it does not improve symptoms of rotator cuff TEAR - MRI is excellent at visualizing soft tissue structures and is the study of choice for diagnosing rotator cuff tears

Question 70

what can shoulder x-ray diagnose?

Answer 70

-fractures, dislocations, and calcific tendonitis

Question 71

Multiple myeloma presentation

Answer 71

- pain in the spine, ribs, or back | - may be accompanied by hypercalcemia and anemia

Question 72

Fat embolism

Answer 72

- presents w/ dyspnea, confusion and petechiae in the upper part of the body and occurs after multiple fractures of long bones - severe respiratory distress, petechial rash, subconjunctival hemorrhage, tachycardia, tachypnea, and fever - diagnosis can be confirmed by FAT DROPLETS IN URINE or presence of intra-arterial fat globules on fundoscopy; may occur 12 to 72 hrs after the injury - serial x-rays shows increasing diffuse bilateral pulmonary infiltrates within 24-48 hrs of onset of clinical findings - tx: prompt respiratory support (use of heparin, steroids, LMW dextran is controversial)

Question 73

air embolism

Answer 73

- can occur in a trauma patient who is on a respirator, or with subclavian vein access - can result in sudden collapse and cardiac arrest

Question 74

amniotic fluid embolism

Answer 74

-occurs immediately after the rupture of membranes

Question 75

Thromboembolism

Answer 75

-can cause pulmonary embolism in bed-ridden patient

Question 76

what does morning stiffness indicate?

Answer 76

INFLAMMATORY arthritides

Question 77

Psoriatic arthritis

Answer 77

- occurs in 5-30% of pts w/ psoriasis - classic presentation involves the DIP joints - morning stiffness, deformity, dactylitis (sausage digit), and nail involvement are common - current tx options for psoriatic arthritis include NSAIDs, methotrexate, and anti-TNF alpha agents

Question 78

tophi

Answer 78

cutaneous deposits of monosodium urate crystals in chronic gout -commonly occur over joints and the helix of the ear, and may ulcerate

Question 79

Gottron's papules

Answer 79

- violaceous plaques, slightly scaly - can present with dermatomyositis - usually over the MCP joints, which at times can look similar to psoriasis

Question 80

Enteropathic arthritis

Answer 80

- occurs in 10-20% of pts w/ Chron disease and UC - most often affects the lower extremities and sacroiliac joints and tends to wax and wane w/ the symptoms of bowel disease - these pts have prominent GI symptoms and other extraintestinal manifestations of inflammatory bowel disease

Question 81

Neuropathic arthropathy (Charcot joint)

Answer 81

- most commonly affects the lower limbs - most cases occur w/ diabetes, but syphilis and alcoholism are other causes - peripheral neuropathy is believed to result in decreased proprioception, which leads to frequent trauma and eventual destruction of the joint

Question 82

Rheumatoid arthritis often presents w/ morning stiffness (indicating inflammatory etiology). The MCP and PIP joints are prominently involved, whereas the DIP joints classically are not. Dactylitis and nail involvement are also not expected in RA

Answer 82

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Question 83

joint and skin involvement in sarcoidosis?

Answer 83

- polyarthritis affecting the ankles and knees - causes protean cutaneous manifestations, the most common of which is ERYTHEMA NODOSUM - also often have cough, chest pain, and dyspnea

Question 84

Bowel ischemia (colonic ischemia)

Answer 84

- may complicate up to 7% of procedures on the aortoiliac vessels and most commonly affects the distal left colon - pts report dull pain over the ischemic bowel as well as hematochezia - colonoscopy shows a discrete segment of cyanotic and ulcerated bowel

Question 85

Acute diverticulitis typically does not present with rectal bleeding, while diverticulosis does

Answer 85

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Question 86

radiation proctitis

Answer 86

- diarrhea, rectal bleeding, tenesmus and incontinence | - later, strictures and fistulae may form

Question 87

C. diff colitis (pseudomembranous colitis)

Answer 87

- abdominal pain, fever, and watery diarrhea | - diagnose by detecting toxin in the stool w/ ELISA

Question 88

IBD can be differentiated from colonic ischemia both by the acute onset of the latter as well as differences in appearance on colonoscopy. Namely, ischemia typically spares the rectum and involves only a segment of the colon while IBD does not.

Answer 88

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Question 89

Glasgow coma scale (GCS)

Answer 89

- all trauma pts should be triaged using the GCS, which can predict the severity and prognosis of coma, during the primary survey. - the GCS assesses the patient's ability to open his/her eyes, motor response, and verbal response

Question 90

All pts w/ smoke inhalation should be suspected to have what?

Answer 90

- acute carbon monoxide poisoning - tx w/ 100% oxygen via a nonrebreather facemask - early symptoms of carbon monoxide poisoning are typically neurological and include agitation, confusion, and somnolence - diagnosis confirmed clinically and documenting an elevated carboxyhemoglobin level (> 3% in nonsmokers and > 15% in smokers) - pulse ox is unreliable!

Question 91

a bolus of 50% dextrose and IV thiamine is indicated in any unconscious patient as an emergency measure to assess for hypoglycemia.

Answer 91

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Question 92

Volkmann's ischemic contracture

Answer 92

-the final sequel of compartment syndrome in which the dead muscle has been replaced w/ fibrous tissue

Question 93

Reflex sympathetic dystrophy

Answer 93

- vague painful condition seen as a sequel of infection on trauma which may be minor - characterized by pain, hyperesthesia and tenderness, which are out of proportion to the physical findings - Sudeck's atrophy is a radiographic term for spotty rarefaction seen in pts w/ RSD

Question 94

manifestations of SLE

Answer 94

- constitutional: fever, fatigue and weight loss - symmetric, migratory arthritis - butterfly rash and photosensitivity - serositis: pleurisy, pericarditis, and peritonitis - thromboembolic events (due to vasculitis and antiphospholipid antibodies) - cognitive dysfunction and seizures - hemolytic anemia, thrombocytopenia, and leukopenia - HYPOCOMPLEMENTEMIA (c3 and c4) - ANA (sensitive) and ANTI-dsDNA and ANTI-SM (specific) - renal involvement: proteinuria and elevated creatinine

Question 95

Systemic Lupus Erythematosus (SLE)

Answer 95

- autoimmune disease that is most commonly diagnosed in young women - more than 90% of patients w/ SLE have joint involvement, most often affecting the hands - Joint pain may be severe but SLE induced arthritis is usually NON-DEFORMING (unlike RA)

Question 96

Tx of joint symptoms in SLE

Answer 96

- most pts will respond to conservative treatment w/ NSAIDs | - low dose glucocorticoids or antimalarials (eg hydroxychloroquine) can be added for more severe joint symptoms

Question 97

"pencil-in-cup" deformities

Answer 97

-distal phalangeal resorption is characteristic of the ARTHRITIS MUTILANS variant of psoriatic arthritis

Question 98

Cartilage degradation is the underlying pathologic mechanism of osteoarthritis (OA). Pts w/ OA may develop muscle atrophy from limitations of joint movement.

Answer 98

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Question 99

Subluxation of the cervical vertebrae and tendon damage in the hands may occur in RA

Answer 99

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Question 100

SLE

Answer 100

- autoimmune disease most commonly diagnosed in young women - 90% of pts have joint involvement, most often affecting the hands - joint pain may be severe but SLE induced arthritis is usually NON-DEFORMING (ie no bone resorption or subluxation or permanent deformity)

Question 101

Inflammatory breast cancer

Answer 101

- uncommon - presents w/ an erythematous and brawny edematous cutaneous plaque overlying a mass on the breast commonly with axillary lymphadenopathy - 25% of pts w/ this condition will have metastatic disease at time of presentation

Question 102

Nipple discharge in a NON-lactating women should ALWAYS raise suspicion for breast cancer, especially if spontaneous, unilateral, localized to a single duct, occurs in a patient over 40 years old, is bloody, or is associated with a mass! Biopsy with histology must be done

Answer 102

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Question 103

mastitis

Answer 103

- typically in younger lactating women - tx w/ an antibiotic that covers Staph and Strep, and encourage continued breast feeding or breast pumping of the affected breast

Question 104

cellulitis of breast that fails to respond to empiric antibiotic therapy

Answer 104

- biopsy for culture | - acid-fast organisms and fungi may rarely cause mastitis and breast abscess

Question 105

Rheumatic fever

Answer 105

- preventable complication of streptococcal group A pharyngitis - usually precedes the onset of rheumatic fever by 2-4 weeks - diagnosed clinically using Jones criteria (2 major, or 1 major and 2 minor) - Criteria includes, major: Carditis, migratory polyarthritis, sydenham chorea, subcutaneous nodules, and erythema marginatum; minor: fever, arthralgias, elevated ESR/CRP, prolonged PR interval - supportive lab findings: positive strep antigen test or elevated ASO titer - prevented w/ treatment w/ penicillin of strep pharyngitis

Question 106

ALL

Answer 106

-malignancy of WBC's that causes lymphocytosis or lymphopenia along w/ anemia or thrombocytopenia

Question 107

Juvenile idiopathic arthritis

Answer 107

- diagnosed when arthritis is present > 6 weeks | - systemic symptoms including rash, can be seen in children with JIA, but the arthritis is usually NOT migratory

Question 108

Henoch-Schonlein purpura

Answer 108

-small vessel vasculitis that can cause a transient, migratory arthritis and rash that is purpuric (arthritis typically involves lower joints)

Question 109

Acute rheumatic fever

Answer 109

- peak incidence age 5-15; twice as common in girls - Major: Joints (migratory arthritis), Carditis, Nodules (subcutaneous), Erythema marginatum, Sydenham chorea - Minor: fever, arthralgias, elevated ESR/CRP, Prolonged PR interval - late sequelae: mitral regurgitation/stenosis - prevention: penicillin for GROUP A STREP (strep pyogenes) pharyngitis - diagnosis based on evidence of preceding group A strep infection along w/ 2 major criteria, or 1 major plus 2 minor criteria

Question 110

SLE

Answer 110

- autoimmune disease that affects multiple organ systems - arthritis and elevated CRP/ESR can be seen, but the rash is usually present across the cheeks (malar rash). - Multiple organ system involvement (eg, hematologic, neurologic, renal) is needed for the diagnosis

Question 111

diagnostic criteria for SLE?

Answer 111

SOAP BRAIN MD -Serositis (pleuritis/pericarditis) -Oral ulcers -Antinuclear antibody (ANA)- very SENSITIVE -Photosensitivity (skin rash to sunlight) -Blood (hemolytic anemia, leukopenia, thrombocytopenia) -Renal (proteinuria and cell casts) -Arthritis (symmetric, involving 2+ small or large peripheral joints) -Immunologic (anti-dsDNA) -Neurological (seizures, psychosis) Note that anti-smith antibodies are the most SPECIFIC for SLE! -Need 4 out of 11 to diagnose SLE

Question 112

Acute appendicitis

Answer 112

- CLINICAL diagnosis - classic presentation of migratory RLQ pain, nausea, vomiting, fever, leukocytosis, McBurney point tenderness, and Rovsing sign should have IMMEDIATE appendectomy to prevent appendiceal rupture. - imaging studies such as CT and US are useful for pts with NONCLASSIC symptoms, equivocal findings on initial assessment, or delayed presentation

Question 113

Role of antibiotics in appendicitis?

Answer 113

- Abx should be given PREoperatively to all pts and should be continued POSToperatively for those w/ appendiceal rupture - pts w/ appendicitis who have had symptoms > 5 days usually have a PHLEGMON with an abscess that has walled off; they can be managed conservatively w/ IV abx, bowel rest, and delayed appendectomy weeks later

Question 114

Presentation of cardiac tamponade

Answer 114

hypotension, tachycardia, distant heart sounds, neck vein distension, ELECTRICAL ALTERNANS (varying amplitude of the QRS complexes from beat to beat) on ECG

Question 115

Blunt abdominal trauma

Answer 115

- often causes splenic injury which can present w/ delayed onset hypotension, LUQ pain, and left shoulder pain (Kehr sign) - pts should have an abdominal CT scan w/ IV contrast for diagnosis - those w/ persistent hemodynamic instability require urgent laparotomy

Question 116

Patellofemoral syndrome

Answer 116

- very common cause of anterior knee pain - symptoms are chronic and associated w/ activities such as CLIMBING STAIRS w/ extension at the knee - women are affected much more often than men - diagnosis is based on history and physical exam; tx involves stretching and strengthening the thigh muscles in addition to avoiding activities that worsen the pain - risk factors include overuse, malalignment, and trauma - diagnostic test includes the PATELLAR GRIND TEST (patellofemoral compression test) and reproduction of pain w/ squatting - subacute to chronic pain, increased w/ squatting, running, prolonged sitting, using stairs

Question 117

patellar tendonitis

Answer 117

- primarily athletes ("jumper's knee") | - episodic pain and tenderness at inferior patella

Question 118

Osgood-Schlatter disease

Answer 118

- preadolescent/adolescent athletes; recent growth spurt | - increased pain w/ sports, relieved by rest; tenderness and swelling at tibial tubercle

Question 119

Penile fracture

Answer 119

- surgical EMERGENCY that requires emergent urethral imaging (retrograde urethrogram) and surgical repair - the most common cause is a crush injury of the erect penis, most commonly during intercourse where the female is on top of the male - often accompanied by snapping sensation or sound, followed by severe pain and swelling; due to tearing of the tunica albuginea, which invests the corpus cavernosum

Question 120

Circumsision

Answer 120

- treatment of choice for phimosis, paraphimosis, and Zoon's balanitis - also associated w/ lower risk of squamous cell carcinoma of the penis

Question 121

Acute mediastinitis

Answer 121

- can occur following cardiac surgery that is usually due to intra-op wound contamination and presents w/ fever, chest pain, leukocytosis, and mediastinal widening on chest x-ray - its a serious condition that requires drainage, surgical debridement, and prolonged antibiotic therapy - typically presents within 14 days post-op - clinical diagnosis and confirmed during surgery when pus is seen in mediastinum - high mortality rate even with appropriate treatment

Question 122

Atrial fibrillation commonly (up to 15-40%) occurs within a few days after CABG and is usually self-limited, w/ resolution in 24 hours after CABG.

Answer 122

.

Question 123

treatment for pericarditis

Answer 123

NSAIDS

Question 124

Postpericardiotomy syndrome

Answer 124

- fever, leukocytosis, tachycardia, and chest pain - usually autoimmune and occurs a few weeks following a procedure with a pericardium incision - NSAIDS or steroids treat the inflammation, and pericardial puncture is indicated if tamponade occurs

Question 125

what to do with amputated part in traumatic amputations?

Answer 125

- amputate parts should be wrapped in saline-moistened sterile gauze, sealed in a plastic bag, placed on a bed of ice and brought to the ED with the patient - younger pts w/ sharp amputations w/ no crush injury or avulsion are the best candidates for amputation reimplantation

Question 126

Baker cysts

Answer 126

- develop as a result of excessive fluid production by an inflamed synovium, as occurs in cases of RA, osteoarthritis, and cartilage tears - the excess fluid accumulates in the popliteal bursa which expands, creating a tender mass in the popliteal fossa - baker cysts occasionally burst and release their contents into the calf, resulting in an appearance similar to a DVT

Question 127

MCL tears

Answer 127

- MCL is most commonly injured ligament of the knee - surgery is rarely necessary for MCL tears; bracing and early ambulation is the preferred treatment - MRI is the investigation of choice for defining soft tissue injuries of the knee

Question 128

If a patient develops a whistling noise during respiration following rhinoplasty, what should you suspect?

Answer 128

- Nasal septal perforation likely resulting from a septal hematoma - up to 25% of rhinoplasties need to be revised - common complications include patient dissatisfaction, nasal obstructions and epistaxis; those that involve the nasal septum are less common but more serious - additional conditions that can cause septal perforation are self-inflicted trauma (nose picking), syphilis, TB, intranasal cocaine use, sarcoidosis, and granulomatosis w/ polyantiitis (Wegener's)

Question 129

nasal polyps

Answer 129

- usually seen in pts w/ asthma and allergic disorders but may also occur in pts w/ other inflammatory conditions of the nasal mucosa - they may cause chronic nasal obstruction and should be surgically removed in symptomatic pts

Question 130

foreign bodies in nose

Answer 130

- common in children - pts will have nasal obstruction and may have a foul odor, halitosis, and nasal bleeding - following surgery, a retained foreign body such as nasal packing most classically would cause toxic shock syndrome

Question 131

allergic rhinitis

Answer 131

- presents w/ rhinorrhea, nasal pruritis, cough and occasionally dyspnea - on exam, the nasal mucosa is edematous and pale, and polyps may be present

Question 132

nasal furunculosis

Answer 132

- results from staphylococcal folliculitis following nose picking or nasal hair plucking - potentially life threatening as it can spread to the cavernous sinus - pts may complain of pain, tenderness, and erythema in the nasal vestibule

Question 133

management of a suspected urethral injury?

Answer 133

- Retrograde urethrogram should be first step! - foley catheterization in the presence of a urethral injury will predispose the patient to abscess formation and worsening of the urethral damage - classic signs of posterior urethral injury include blood at the urethral meatus, inability to void and a high-riding prostate on digital rectal exam. Perineal or scrotal hematomas are also frequently seen and such an injury is most classically associated w/ pelvic fracture

Question 134

how are urethral injuries managed?

Answer 134

- Retrograde urethrogram is almost always the first step - immediate surgical repair is occasionally done in cases of ANTERIOR urethral injury - most cases of urethral injury are treated w/ urinary diversion via a suprapubic catheter while the primary injury and associated hematomas are allowed to heal. After healing is complete, residual damage, such as urethral stricture, is assessed and repaired

Question 135

Retrograde cystogram with post void films

Answer 135

- used for diagnosis of BLADDER INJURY - may occur following major trauma, especially pelvic fracture - pts typically complain of gross hematuria

Question 136

Ileus can occur as a result of a vagal reaction caused by ureteral colic from kidney stones. Needle-shaped crystals on urinalysis indicate uric acid stones! Uric acid stones are radiolucent, and must be evaluated by abdominal CT, US, or IV pyelography. Ileus will resolve when the ureterolithiasis is treated. Stones

Answer 136

.

Question 137

Colonoscopy is NOT indicated for right-sided pathology and should NOT be performed in ACUTE pathology of the bowel wall due to the risk of perforation.

Answer 137

.

Question 138

Enteroclysis

Answer 138

-used to diagnose small bowel tumors and other pathology, which can cause intestinal obstruction

Question 139

What should ALWAYS be obtained following placement of central venous catheter?

Answer 139

Chest x-ray to confirm proper placement of the catheter tip and absence of complications before administering drugs or other agents through the catheter - complications: arterial puncture, pneumothorax, hemothorax, thrombosis, air embolism, sepsis, vascular perforation, myocardial perforation leading to tamponade - catheter tip should be located proximal to either the cardiac silhouette or the angle between the trachea and the right mainstem bronchus; ideally in the superior vena cava

Question 140

Esophageal rupture (Boerhaave syndrome)

Answer 140

- most commonly occurs following instrumentation of the esophagus - less commonly, it may occur in pts w/ protracted vomiting who have been resisting the urge to vomit; rupture in these cases typically occurs into the mediastinum resulting in pneumomediastinum; rupture typically occurs a few centimeters above the gastroesophageal junction - retrosternal chest pain and crepitus in the suprasternal notch are common following rupture of esophagus within the mediastinum

Question 141

True or false: acute pancreatitis can cause a left sided pleural effusion?

Answer 141

True

Question 142

perforated duodenal ulcer

Answer 142

-epigastric pain and air would be visualized under the diaphragm on upright abdominal x-ray, but pneumomediastinum is NOT associated w/ duodenal perforation

Question 143

Mallory-Weiss tear

Answer 143

- an INCOMPLETE mucosal tear at the gastroesophageal junction usually resulting from protracted vomiting - the common presentation is self-limited hematemesis - pneumomediastinum does NOT occur in such tears because the rupture is incomplete

Question 144

Serum sickness-like reaction

Answer 144

- most commonly caused by antibiotics (B-lactams and sulfa drugs) - symptoms arise 1-2 weeks after exposure and include fever, urticarial rash, arthralgia, and lymphadenopathy. the abnormalities should resolve within 48 hours w/ withdrawal of the offending agent. some cases may need steroid treatment - type III hypersensitivity reaction - lab findings: nonspecific hypocomplementemia and elevated ESR/CRP, which are consistent with any type III hypersensitivity reaction

Question 145

acute rheumatic fever

Answer 145

- can follow untreated strep pharyngitis and may present w/ frank arthritis, erythema marginatum, and fever - ARF after appropriate antibiotic therapy is extremely rare and highly unlikely

Question 146

Anaphylaxis

Answer 146

- presents acutely w/ skin changes plus hypotension, respiratory distress, or GI symptoms - type 1 hypersensitivity reaction

Question 147

Henoch-Schonlein purpura

Answer 147

- systemic IgA-mediated vasculitis occurring after an upper respiratory infection - presents w/ fever, arthralgia, and a palpable purpuric rash of the lower extremities

Question 148

Mononucleosis

Answer 148

- presents as fever, cervical lymphadenopathy, pharyngitis, and malaise - those treated w/ an aminopenicillin can develop a MORBILLIFORM (measles-like) rash on the trunk; however, the rash typically spares the extremities and arthralgia does not occur

Question 149

Scarlet fever

Answer 149

-presents w/ fever, and scarlatiniform "sandpaper" rash following strep pharyngitis

Question 150

Stevens-Johnson syndrome

Answer 150

- severe mucocutaneous reaction most commonly triggered by medications (eg sulfa drugs, anticonvulsants). - affected pts develop acute high fever, vesicular or bullous lesions, and painful hemorrhagic oral erosions

Question 151

Palpable breast abnormalities

Answer 151

- pts 30 are evaluated w/ mammogram and US - palpable breast masses should generally have an imaging evaluation even if the findings are relatively benign on physical exam - imaging evaluation is helpful both in characterizing the lesion as benign or malignant, and for guiding biopsy if needed

Question 152

physical exam findings of a rubbery, firm, freely mobile mass are suggestive of a fibroadenoma or other benign mass. findings of a hard, irregular, and fixed mass are typically palpated in patients w/ breast malignancies.

Answer 152

.

Question 153

Anterior spinal cord syndrome

Answer 153

- can be due to spinal cord infarction as a potential complication of thoracic aortic aneurysm surgery - typically presents w/ spinal shock (abrupt onset of bilateral flaccid paralysis and loss of pain/temp sensation below the level of spinal injury) - upper motor neuron signs (spasticity and hyperreflexia) subsequently develop over days to weeks - vibration and proprioception are usually preserved - the anterior spinal artery (ASA) supplies the anterior 2/3 of the spinal cord, including motor tracts (eg anterior corticospinal tract) and sensory tracts involved in pain/temp sensation (eg spinothalamic tract); the ASA is particularly dependent on blood supply for the radicular arteries that originate from the thoracic aorta, such as the artery of Adamkiewicz

Question 154

lumbar plexopathy

Answer 154

-peripheral neuropathy characterized by asymmetrical focal weakness, numbness, and paresthesias due to involvement of multiple adjacent nerve roots

Question 155

Medial meniscus tears

Answer 155

- typically injured during forceful torsion of the knee with the foot planted - pts complain of a popping sound and severe pain at the time of injury; McMurray's sign is commonly positive on physical exam - a bucket handle tear of the medial meniscus leads to locking of the knee joint during terminal extension

Question 156

ACL tear

Answer 156

- hx of forceful hyperextension injury to knee or a noncontact torsional injury of the knee during deceleration - effusion is seen rapidly following injury due to the ACL being well-perfused - Lachman's test, anterior drawer test and pivot shift test are used for clinical diagnosis

Question 157

PCL tear

Answer 157

- classically seen in the "dashboard injury", which refers to forceful posterior-directed force on the tibia with the knee flexed at 90 degrees - the posterior drawer, reverse pivot shift and posterior sag tests will help w/ clinical diagnosis

Question 158

Main mechanism responsible for pain relief in pts w/ anginal pain treated w/ nitroglycerin?

Answer 158

- dilation of veins (capacitance vessels) and decrease in ventricular preload - it is unclear whether nitro significantly increases coronary blood flow in pts w/ obstructive coronary heart disease

Question 159

Positive predictive value

Answer 159

- proportion of subjects with a positive test who actually have the disease out of all subjects who test positive for the disease - PPV = TP/TP+FP

Question 160

Negative predictive value

Answer 160

- proportion of subjects with a negative test, and who actually do NOT have the disease out of the total number of people who test negative for the disease - NPV = TN/TN+FN

Question 161

Sensitivity and specificity are useful for assessing the VALIDITY of a test. Predictive values are not true indices of the validity of a test, but are still important because pts present with positive or negative test results, and their true disease state is frequently unknown.

Answer 161

.

Question 162

Hyperparathyroidism predisposes to what?

Answer 162

- Pseudogout - pseudogout tends to present as an acute onset, painful monoarthritis affecting the knee; rhomboid shaped, positively birefringent crystals are diagnostic of pseudogout - hyperparathyroidism causes elevated calcium levels and low phosphorus concentrations. Subsequently hypercalcemia can cause constipation, fatigue, excessive urination, abdominal pain, urinary stones, mental status changes, and osteoporosis

Question 163

Gout

Answer 163

- needle shaped crystals w/ NEGATIVE birefringence | - presents as acute onset, painful monoarthropathy

Question 164

Struvite crystals

Answer 164

-have the shape of coffin lids and are seen in nephrolithiasis caused by chronic UTI with urease-producing organisms

Question 165

otitis externa vs malignant (necrotizing) otitis externa

Answer 165

- topical antibiotics and corticosteroids are appropriate for otitis externa, but not for malignant otitis externa, which requires IV abx and possible debridement if no response to abx - the severity of pain, presence of granulation tissue, and elevated ESR are all clues that distinguish OE from MOE

Question 166

antibiotics effective against Pseudomonas aeruginosa

Answer 166

- Anti-pseudomonal penicillins: Ticarcillin, Piperacillin - Cephalosporins: Ceftazidime (3rd gen), Cefepime (4th gen) - Aminoglycosides: Amikacin, Gentamicin, Tobramycin - Fluoroquinolones: Ciprofloxacin, Levofloxacin - Monobactams: Aztreonam - Carbapenems: Imipenem, Meropenem

Question 167

Malignant (necrotizing) otitis externa

Answer 167

- severe infection of the external auditory canal and skull base usually caused by Pseudomonas aeruginosa - its seen most frequently in elderly pts w/ diabetes or immunosuppression - presents as severe, unrelenting ear pain (especially prominent at night), purulent drainage w/ a sense of fullness, and conductive hearing loss on the affected side. Otoscopy shows granulation tissue and an edematous external auditory canal - as the infection spreads beyond the external auditory canal, osteomyelitis of the skull base or TMJ can develop and present w/ pain exacerbated by chewing - EMPIRIC TREATMENT WITH IV CIPROFLOXACIN

Question 168

Hazard ratios

Answer 168

- proportions that indicate the chance of an event occurring in the treatment group compared to the chance of the event occurring in the control goup - when reviewing a drug advertisement, it is important to critically read all presented info - hazard ratios 1 signifies that an event is more likely to occur in the treatment group. A ratio close to 1 implies little difference between the two groups. In addition, if the 95% confidence interval contains the null value of 1, this indicates that there is no significant difference between the two groups.

Question 169

Successful randomization in a clinical trial

Answer 169

- allows a study to eliminate bias in treatment assignments - an ideal randomization process minimizes selection bias, results in near-equal treatment and control group sizes, and achieves a low probability of confounding variables

Question 170

The null hypothesis

Answer 170

- is always the statement of NO RELATIONSHIP between the exposure and the outcome - to state the null hypothesis correctly, you should recognize the study design first

Question 171

what is the key pathogenic factor in the development of type 2 DM and associated abnormalities (hypertension, dyslipidemia)?

Answer 171

-Insulin resistance typical for pts w/ central-type obesity!

Question 172

Metabolic syndrome

Answer 172

- hypertension, impaired fasting glucose, and dyslipidemia - pts are also characteristically overweight w/ predominantly central (abdominal) fat distribution - Insulin resistance plays a central role in the pathogenesis of the metabolic syndrome - Diagnosis of the metabolic syndrome is based on at least 3 of the 5 following criteria: 1. abdominal obesity (men: waist circuference > 40 in; women: waist circumference > 35 in) 2. fasting glucose > 100 - 110 mg/dL 3. BP > 130/80 4. Triglycerides > 150 mg/dL 5. HDL (men:

Question 173

Insulin resistance is associated w/ several other systemic effects such as?

Answer 173

-dyslipidemia, endothelial dysfunction, procoagulable state, increased sympathetic activity, increased markers of inflammation, decreased uric acid excretion, increased sodium absorption, disordered breathing and increased testosterone production from the ovaries

Question 174

In clinical trials, randomization is said to be successful when a similarity of baseline characteristics of the patients in the treatment and placebo groups is seen

Answer 174

.

Question 175

Tx of uncomplicated cystitis

Answer 175

- Nitrofurantoin for 5 days (avoid in suspected pyelonephritis or creatinine clearance 20%) - Fosfomycin single dose - Fluoroquinolones only if above options cannot be used - Urine culture needed only if initial treatment fails

Question 176

Tx of complicated cystitis

Answer 176

- Fluoroquinolones for 5-14 days (do NOT use in pregnancy; consider nitorfurantoin, amoxicillin, and cephalexin instead), extended spectrum abx (ampicillin/gentamicin) for more severe cases - obtain sample for urine culture prior to initiating therapy and adjust abx as needed - associated w/ diabetes, pregnancy, renal failure, urinary tract obstruction, indwelling catheter, urinary procedure (eg cystoscopy), immunosuppression and hospital-aquired

Question 177

Tx of pyelonephritis

Answer 177

- Outpatient: fluoroquinolones (eg ciprofloxacin, levofloxacin) - Inpatient: IV abx (fluoroquinolone, aminoglycoside +/- ampicillin) - obtain sample for urine culture prior to initiating therapy and adjust abx as needed

Question 178

Uncomplicated cystitis

Answer 178

- commonly occurs in otherwise healthy pts and has a low risk of tx failure - UA confirms diagnosis - Pts can be tx without a urine culture, which may be done later in those who fail initial therapy - oral TMP/SMX, nitrofurantoin, and fosfomycin are effective first-line tx options - presents w/ dysuria, urinary frequency, and suprapubic tenderness

Question 179

Recommended vaccines for chronic liver disease

Answer 179

- Tdap/Td: Tdap once as substitute for Td booster, then Td every 10 years - Influenza: annually - Pneumococcal vaccines: PPSV23 once, then revaccination w/ sequential PCV13 and PPSV23 at age 65 - Hepatitis A: 2 doses 6 months apart with initial negative serologies - Hepatitis B: 3 doses at 0 months, 1 month and at least 4 months w/ initial negative serologies

Question 180

Pneumococcal vaccines

Answer 180

- the 13-valent pneumococcal conjugate vaccine (PCV13) is recommended initially for all adults age > 65 followed by the 23-valent pneumococcal polysaccharide vaccine (PPSV23) after at least 6-12 months - for adults age

Question 181

Following splenectomy, pts are at increased risk for sepsis due to encapsulated organisms including Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. Vaccinations against each of these organisms should be administered either > 14 days before scheduled splenectomy or > 14 days after splenectomy.

Answer 181

.

Question 182

most common cause of sepsis in post-splenectomy pts?

Answer 182

-Strep pneumoniae

Question 183

Strep pneumo vaccination in asplenic pts

Answer 183

- following splenectomy, the 13-valent pneumococcal conjugate vaccine (PCV13) should be given first, followed by the 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least 8 weeks later. Pts need revaccination w/ PPSV23 fiver years later and again at age 65 - all pts should receive vaccines either >14 days before scheduled splenectomy or > 14 days after splenectomy

Question 184

hepatorenal syndrome

Answer 184

- seen in pts w/ severe liver cirrhosis secondary to systemic and renal hypoperfusion - pts have acute renal failure (creatinine > 1.5 mg/dL) w/ a very low urine sodium level, typically

Question 185

Pathophysiology of hepatorenal syndrome

Answer 185

- pts w/ severe liver cirrhosis have increased nitric oxide generation in the splanchnic circulation secondary to portal hypertension. This is thought to cause systemic vasodilation, which reduces peripheral vascular resistance and BP, causing renal hypoperfusion. Reduced renal perfusion would then activate compensatory pathways (the renin-angiotensin-aldosterone system, sympathetic nervous system, and antidiuretic hormone) that increase water and sodium retention and worsen volume overload. Any factor that may further reduce glomerular capillary pressure (such as hypotension from GI bleeding) causes an acute decline in glomerular filtration and can precipitate hepatorenal syndrome. - lab results are similar to those of prerenal azotemia: elevated serum creatinine (> 1.5 mg/dL) and a very low urine sodium level, typically

Question 186

common glomerular disease associated with Hepatitis C infection?

Answer 186

Membranoproliferative glomerulonephritis

Question 187

Interstitial nephritis

Answer 187

-usually presents w/ eosinophils or leukocytes in the urine

Question 188

Remember that acute kidney injury is NOT seen in obstructive uropathy unless BOTH URETERS ARE OBSTRUCTED!!!!

Answer 188

.

Question 189

Renal vein thrombosis

Answer 189

- usually occurs in pts w/ a predisposing condition, such as hypercoagulability, trauma, nephrotic syndrome, or severe dehydration - acute renal vein thrombosis presents w/ abdominal pain and hematuria

Question 190

Nonalcoholic fatty liver disease (NAFLD)

Answer 190

- resembles alcohol-induced liver injury on histology but occurs in pts w/ minimal or no alcohol hx - most likely mechanism is insulin resistance leading to increased peripheral lipolysis, triglyceride synthesis, and hepatic uptake of fatty acids - definition: hepatic steatosis on imaging or biopsy; exclusion of significant alcohol use; exclusion of other causes of fatty liver - features: mostly asymptomatic; metabolic syndrome; +/- steatohepatitis (AST/ALT ratio 35 - macrovesicular fat deposition and peripheral displacement of the nucleus

Question 191

Approximately 10-20% of pts on isoniazid will develop mild aminotransferase elevation within the first few weeks of treatment. This hepatic injury is typically self-limited and resolve without intervention. Liver enzymes should be

Answer 191

.

Question 192

Diabetic nephropathy

Answer 192

- begins w/ HYPERfiltration (increased GFR) and microalbuminuria (incipient nephropathy); if not treated adequately, microalbuminuria may progress to macroproteinuria, defined as urine protein excretion > 300 mg/24 hrs; this increase in urinary protein is accompanied by a progressive decline in GFR - the most beneficial therapy to reduce progression of diabetic nephropathy is STRICT BLOOD PRESSURE CONTROL; pts w/ diabetic nephropathy should be treated toward a target BP of 130/80 mmHg - ACE inhibitors or ARBs are first-line tx for pts w/ diabetes mellitus, but must be initiated carefully as they may induce an acute decline in GFR and hyperkalemia

Question 193

daily protein recommendations for pts w/ diabetic nephropathy and azotemia?

Answer 193

-0.8g/kg/day protein

Question 194

Intensive glycemic control (HbA1c

Answer 194

.

Question 195

Pts w/ mild primary hyperaldosteronism may not have spontaneous hypokalemia, but they are prone to developing diuretic-induced hypokalemia. Other findings include metabolic alkalosis and mild hypernatremia (143-147 mEq/L). The best screening test is early-morning plasma aldosterone concentration (PAC) to plasma renin activity (PAC) ratio. A PAC/PRA ratio > 20 w/ plasma aldosterone > 15 ng/dL suggests primary hyperaldosteronism.

Answer 195

.

Question 196

Secondary hyperaldosteronism

Answer 196

- causes: diuretic use, cirrhosis or CHF, renovascular HTN (renal artery stenosis or fibromuscular dysplasia), renin-secreting tumor, malignant HTN, coarctation of aorta - Increased plasma renin activity and plasma aldosterone concentration, but with a PAC/PRA ratio

Question 197

Dexamethasone suppression test

Answer 197

- can diagnose Cushing's syndrome | - central obesity, purple striae, proximal muscle wasting, glucose intolerance, and HTN

Question 198

what is the preferred initial screening test for primary hyperaldosteronism?

Answer 198

- the ratio of plasma aldosterone concentration to plasma renin activity via early morning sampling; a PAC/PRA ratio > 20 with plasma aldosterone > 15 ng/dL suggests primary hyperaldosteronism - adrenal suppression testing is then used to confirm diagnosis, and positive tests requires adrenal imaging by CT. Adrenal vein sampling is the most SENSITIVE test for differentiating adrenal adenoma and bilateral adrenal hyperplasia in pts w/o discrete unilateral adrenal mass on imaging, can then be done to differentiate between hyperplasia and adenoma. Surgery for adenoma, medical therapy for hyperplasia.

Question 199

pheochromocytoma

Answer 199

- plasma free metanephrines would be elevated | - HTN and the classic triad of episodic headache, sweating, and palpitations w/ tachycardia

Question 200

management of pts w/ hyperkalemia and significant EKG changes (QRS prolongation and peaked T waves)?

Answer 200

-therapy includes emergent administration of IV calcium gluconate to stabilize the cardiac membrane, then lowering serum potassium by driving potassium intracellularly with insulin and glucose, sodium bicarb, or beta-2 agonists such as albuterol; the final step would be to excrete excess potassium by elimination from the body.

Question 201

example of an alpha 1 agonist

Answer 201

-phenylephrine

Question 202

beta 1 agonists have chronotropic and inotropic effects

Answer 202

.

Question 203

alpha 1 antagonists

Answer 203

-cause peripheral vasodilation, and are used in the tx of HTN and BPH

Question 204

beta 1 blockers

Answer 204

-commonly used in tx of HTN, heart failure, and atrial fibrillation

Question 205

most health care providers believe that insulin resistance is the first event in the development of type 2 DM; however, type 2 DM does NOT develop without a beta cell secretory defect. Increased insulin secretion from the beta cells is required to cope with increased insulin resistance. If beta cells are able to compensate for the increased insulin resistance, subjects generally remain normoglycemic at the expense of very high insulin levels; however, if beta cells are unable to compensate fully, glucose intolerance and type 2 DM results.

Answer 205

.

Question 206

Tempromandibular joint (TMJ) dysfunction

Answer 206

- can result in referred pain to the ear that is worsened with chewing - pts typically report a hx of nocturnal teeth grinding - pain is worsened w/ chewing; some hear audible clicks or crepitus w/ jaw movement, but not always - initial tx consists of conservate measure such as nighttime bite guard, but surgical intervention is sometimes necessary

Question 207

Ramsay Hunt syndrome

Answer 207

- form of herpes zoster infection that causes Bell's palsy | - vesicles are typically seen on the outer ear

Question 208

Glossopharyngeal neuralgia

Answer 208

-pts experience intermittent, severe, stabbing pain in areas innervated by CN IX and X, which includes the ear.

Question 209

Otitis media

Answer 209

-can result in ear pain, but it will usually cause erythema and/or limited mobility of the TM

Question 210

Otitis externa

Answer 210

-usually results in ear discharge and pain w/ pulling on the pinna

Question 211

Cerumen impaction

Answer 211

-usually causes conductive hearing loss as opposed to pain

Question 212

Diabetic ketoacidosis (DKA)

Answer 212

- presents w/ metabolic acidosis, polyuria, dehydration, decreased level of consciousness, and diffuse abdominal pain, and is often precipitated by acute infection - DKA is characterized by an osmotic diuresis that reduces total body potassium stores even though serum potassium level may be elevated - occurs in type 1 DM - infection can precipitate DKA in type 1 DM due to systemic release of insulin couterregulatory horomes such as catecholamines and cortisol; the resultant excess of glucagon causes hyperglycemia, ketonemia, and an osmotic diuresis; this diuresis is accompanied by a net renal loss of potassium w/ depletion of total body potassium stores; despite reduction in TOTAL body potassium, the SERUM potassium concentration may be elevated due to acidemia and decreased insulin activity, causing redistribuation of potassium to ECF compartment - mild leukocytosis may also be seen - reduction in effective circulating blood volume, which activates the RAAS and accelerates renal potassium losses - increase in circulating free fatty acids due to underlying relative excess of glucagon to insulin and consequent increase in lipolysis - hyperglycemia in DKA contributes not only to osmotic diuresis and hypovolemia but also to serum HYPERosmolality, which will most likely promote pituitary vasopressin release - hepatic gluconeogenesis would be increased due to both the increased ratio of circulating glucagon to insulin and the increased circulating levels of catecholamines and cortisol - hyperglycemia and hyperketonemia in DKA cause an osmotic diuresis and increased urinary excretion of glucose, ketones, sodium, potassium, Mg, and phosphate

Question 213

Calcium oxalate crystals (rectangular, envelope-shaped crystals) are seen in what?

Answer 213

- pts w/ ETHYLENE GLYCOL (anti-freeze) poisoning | - Ethylene glycol, methanol and ethanol intoxication causes metabolic acidosis w/ both an anion gap and an osmolar gap

Question 214

normal pH

Answer 214

7.35 - 7.45

Question 215

normal anion gap

Answer 215

6-12

Question 216

normal osmolar gap

Question 217

must always calculate anion gap when you have a metabolic acidosis! When the anion gap is markedly elevated and frank uremia is NOT present, the osmolar gap should be calculated to assess for ethanol, methanol, or ethylene glycol intoxication!

Answer 217

.

Question 218

how do you calculate serum osmolality?

Answer 218

serum osmolality = [2Na + Glu/18 + BUN/2.8]

Question 219

how do you calculate the osmolar gap?

Answer 219

osmolar gap = observed osmolarity - calculated osmolarity normal is

Question 220

sequelae following ethylene glycol ingestion

Answer 220

-ARDS, heart failure, renal failure

Question 221

Aspirin (salicylate) toxicity

Answer 221

-causes a MIXED anion gap metabolic acidosis and respiratory alkalosis with NO osmolar gap

Question 222

Methyl alcohol poisoning

Answer 222

-can cause visual changes ("snowfield vision") and acute pancreatitis

Question 223

Uremia (renal failure) causes an anion gap metabolic acidosis due to failure to excrete acids as NH4+

Answer 223

.

Question 224

McCune-Albright syndrome

Answer 224

- rare condition characterized by the 3 P's: Precocious puberty, Pigmentation (cafe au lait spots), and Polyostotic fibrous dysplasia - responsible for 5% of cases of female precocious puberty and may be associated with other endocrine disorders - sporadic and has been attributed to defect in the G-protein cAMP-kinase function in affected tissue

Question 225

Peutz-Jeghers syndrome

Answer 225

- GI tract polyposis and mucocutaneous pigmentation | - may also involve the development of an estrogen-secreting tumor, leading to precocious puberty

Question 226

Sturge-Weber disease

Answer 226

-sporadic phakomatosis characterized by mental retardation, seizures, visual impairment and a characteristic port-wine stain over the territory of the trigeminal nerve

Question 227

Edema, stasis dermatitis, and venous ulcerations result from lower extremity venous insufficiency due to valve incompetence. Such disease classically occurs on the medial leg superior to the medial malleolus. Increased pressure in postcapillary venules causes extravastion of RBCs, leading to hemosiderin deposition in skin causing the characterstic color changes. Venous congestion causes microvascular disease and ultimately ulcerations. Xerosis (dry skin) is the most common early finding; lipodermatosclerosis and ulcerations characterize late disease.

Answer 227

.

Question 228

arterial thrombosis

Answer 228

- classically presents w/ a pt complaining of severe pain in a single extremity - onset of pain is less acute than that seen in arterial occlusion due to EMBOLUS - the extremity typically exhibits coolness to touch, pallor, pulselessness, and paralysis on exam

Question 229

Raynaud disease

Answer 229

- arterial spasm in response to cold or emotional stress causing discoloration and discomfort of the distal digits - may ultimately result in distal digital gangrene if severe

Question 230

Neurosyphilis

Answer 230

may cause tabes dorsalis, a lesion of the posterior spinal cord characterized by loss of proprioceptive sensation from the legs, ataxia, and paresthesias

Question 231

Syringomyelia

Answer 231

-classically presents w/ central cord syndrome; weakness of upper extremities and loss of pain and temp sensation in a "cape-like" distribution over the neck, shoulders, upper arms and hands

Question 232

Cystic fibrosis

Answer 232

- clinical features: chronic sinopulmonary disease (eg bronchiectasis), GI and nutritional abnormalities (eg pancreatic insufficiency, meconium ileus, failure to thrive), salt loss syndromes (eg acute salt depletion, chronic metabolic alkalosis), male urogenital abnormalities (eg obstructive azoospermia) - diagnosis: one or more clinical features OR hx of cystic fibrosis in a sibling OR positive newborn screening test PLUS increased sweat chloride concentration > 60 mmol/L on 2 or more occasions OR identification of 2 CF mutations OR abnormal nasal epithelial ion transport (potential difference) - recurrent respiratory infections, steatorrhea, and failure to thrive are hallmark features. Sweat chloride testing by QUANTITATIVE PILOCARPINE IONTOPHORESIS is the gold standard for diagnosis. Pilocarpine is a cholinergic drug that is applied to the patient's extremity to induce sweating. A chloride level of > 60 mmol/L on 2 separate occasions confirms the diagnosis. Abnormal or intermediate results should be followed by DNA analysis. Nasal potential difference measurement can be performed if sweat testing and DNA analysis are equivocal.

Question 233

Pts w/ X-linked agammaglobulinemia suffer from recurrent sinopulmonary infections and failure to thrive. However, only boys are affected by the Bruton tyrosine kinase gene mutation!

Answer 233

.

Question 234

what is the screening test for primary ciliary dyskinesia?

Answer 234

-Exhaled nasal nitric oxide test

Question 235

Severe combined immunodeficiency syndrome (SCID)

Answer 235

- X-linked or autosomal recessive disorder characterized by recurrent respiratory infections and chronic diarrhea - affected pts have an absolute lymphocyte count

Question 236

The diagnosis of celiac disease is confirmed by the appearance of duodenal villous atrophy on small bowel biopsy

Answer 236

.

Question 237

Congenital toxoplasmosis

Answer 237

- classic triad: chorioretinitis, hydrocephalus, and intracranial calcifications - maternal infection is acquired by exposure to feces from infected cats, or ingestion of infected raw meat or unpasteurized goat's milk - risk of transmission during pregnancy increases as pregnancy progresses, but severity of disease decreases - other complications include: hydrocephalus, microcephaly, hepatosplenomegaly, microphthalmia, microcephaly, diffuse lymphadenopathy, jaundice, diffuse petechiae - lab results show hyperbilirubinemia and thrombocytopenia

Question 238

Congenital syphilis

Answer 238

-intermittent fever, osteitis and osteochondritis, mucocutaneous lesions, lymphadenopathy, hepatomegaly, and persistent rhinitis

Question 239

Congenital rubella syndrome

Answer 239

- microcephaly, microphthalmia, and meningoencephalitis; sensorineural deafness, cardiac anomalies (eg persistent ductus arteriosus, atrial septal defects), congenital glaucoma and cataract - classic triad: deafness, cataracts, and cardiac defects

Question 240

Herpes simplex infection in birth

Answer 240

-encephalitis, chorioretinitis, and disseminated disease

Question 241

Developmental milestones of a 1 year old

Answer 241

- fine motor: two-finger pincer grasp, turns several pages of a book at a time - gross motor: walks w/o assistance, waves bye, climbs up on furniture - language: says 2-3 words, says "mama" and "dada" - social: imitates actions, plays reciprocal games (peek-a-boo), indicates wants

Question 242

developmental milestones of a 2 year old

Answer 242

- fine motor: builds tower of 6 cubes, turns individual pages of a book - gross motor: walks up and down stairs, jumps, throws a ball overhead - language: 200 word vocabulary, uses 2-word phrases, 2-quarters (50%) of speech intelligible - social: follows 2-step commands, remove clothes

Question 243

developmental milestones of a 3 year old

Answer 243

- fine motor: copies a circle, uses utensils to feed self, stacks 9 blocks - gross motor: climbs stairs w/ alternative feet, rides a TRIcycle, kicks a ball - language: uses 3 word sentences, states first name, 3-quarters (75%) of speech intelligible - social: washes/dries hands, helps w/ simple household tasks, group play

Question 244

developmental milestones of a 4 year old

Answer 244

- fine motor: copies a cross, draws a person, begins to use scissors, holds crayon w/ tripod grasp - gross motor: hops on one foot w/o losing balance, jumps over objects - language: counts to 10, tells stories, uses plurals and prepositions - social: cooperative play, has imaginary friends, imitates adult roles

Question 245

Cerebral palsy

Answer 245

- group of syndromes characterized by nonprogressive motor dysfunction; 3 primary subtypes- spastic, dyskinetic, and ataxic - the etiology is often multifactorial, with PREMATURITY as the leading risk factor - affected pts have uncoordinated and limited voluntary movements - risk factors: prematurity, IUG restriction, IU infection, antepartum hemorrhage, placental pathology, multiple gestation, maternal alcohol consumption, maternal tobacco use - managment: physical, occupational and speech therapies; Baclofen and botulinum toxin for spasticity - comorbidities: intellectual disability, epilepsy, strabismus, scoliosis

Question 246

what is the primary medications tx for preeclampsia?

Answer 246

Magnesium sulfate

Question 247

what is the treatment of choice for pregnant pts w/ syphilis? what if they have an allergy to that drug?

Answer 247

- Penicillin is treatment of choice - if patient is allergic to penicillin, the allergy should be confirmed w/ skin testing and the patient should then undergo desensitization using incremental doses of oral penicillin V so that she can safely take the medication

Question 248

adverse effects of Tetracycline during pregnancy?

Answer 248

-harmful effect on teeth and bones of the fetus

Question 249

why can't fluoroquinolones be used during pregnancy?

Answer 249

-musculoskeletal system risks to fetus

Question 250

what is the most common cause (80%) of postpartum hemorrhage within 24 hours of delivery?

Answer 250

- UTERINE ATONY - its important to make a quick diagnosis by checking the firmness and location of the uterus fundus; if bleeding persists despite treatment, other causes should be ruled out - a soft, "boggy", poorly contracted uterus is characteristic - risk factors: uterine overdistention (eg multiple gestation, polyhydramnios, macrosomia) and uterine fatigue (prolonged labor)

Question 251

most common cause of excess postpartum blood loss? Treatment?

Answer 251

- Uterine atony - Initial tx includes bimanual uterine massage (resolves hemorrhage in most cases), fluid resuscitation (SBP > 90), uterotonic agents (eg oxytocin, methylergonovine, carboprost), and blood transfusion as needed

Question 252

when is hysterectomy indicated in postpartum bleeding?

Answer 252

-abnormally adherent placenta (eg placenta accreta), or when all other attempts to control bleeding are unsuccessful or a rupture uterus cannot be repaired

Question 253

when is curettage indicated in postpartum hemorrhage?

Answer 253

-when suspected retained placental tissue; this can be determined by an echogenic mass on US, absence of the normal endometrial stripe on US, or a nonintact placenta on exam

Question 254

Uterine artery embolization or ligation of the uterine or internal iliac arteries can be used for a patient w/ stable vital signs and persistent bleeding if the rate of loss is not excessive. It can also be used as an alternate to hysterectomy in a stable patient who wishes to preserve fertility.

Answer 254

.

Question 255

Postictal lactic acidosis

Answer 255

- commonly occurs following a tonic-clonic seizure - its a transient anion gap metabolic acidosis that resolves without treatment within 60 to 90 minutes following resolution of seizure activity

Question 256

Dopamine is a positive inotrope and a vasoconstrictor used in pts w/ hypotension who do not respond to less aggressive measures such as IV fluids

Answer 256

.

Question 257

Squamous cell carcinoma

Answer 257

- 2nd most common form of non-melanoma skin cancer (after basal cell carcinoma) - the single most important risk factor for the development of squamous cell carcinoma is exposure to sunlight - polygonal cells with atypical nuclei at all levels of the epidermis with zones of keratinization - SCC is more aggressive than basal cell carcinoma because it metastasizes frequently

Question 258

what imaging study would you use to evaluate increasing head circumference and signs of increased intracranial pressure in children?

Answer 258

CT scan of the brain - note that you could also perform a sedate MRI if stable and asymptomatic to spare child from radiation exposure - US is most useful in infants under 6 months of age - Tx of hydrocephalus consists of a shunt that is placed from the ventricle to the peritoneum, pleura, or right atrium

Question 259

when caring for an unemancipated minor, informed consent from one parent or guardian is considered legally sufficient to justify proceeding with therapy. Physicians should also provide care in urgent situations without waiting for parental consent.

Answer 259

.

Question 260

Parents cannot deny their children life-saving treatment unless the benefits are minimal or would not alter the prognosis.

Answer 260

.

Question 261

Circumstances in which minors do not require consent

Answer 261

- medical: emergency care, STIs, substance abuse, prenatal care - emancipated minor: homeless, parent, married, military, financially independent, high school graduate

Question 262

agents used to shift potassium intracellulary

Answer 262

- insulin and glucose - sodium bicarb - beta 2 agonists

Question 263

Medical tx for patients with rheumatoid arthritis?

Answer 263

- ALL pts should receive DMARDs as early as possible in the disease course - Methotrexate is the initial DMARD of choice in most pts w/ active RA - NSAIDS and glucocorticoids should be used for initial temporary symptomatic relief while awaiting response to DMARD therapy; they do NOT alter disease progression however - nonbiologics: methotrexate, hydroxychloroquine, sulfasalazine, leflunomide, azathioprine - biologics: etanercept, infliximab, adalimumab, tocilizumab, rituximab - pts should be tested for hep B and C and TB before starting therapy! - if pts do not respond after 6 months, they may require biologic DMARDs such as TNF-a inhibitors (etanercept, infliximab) as step-up therapy

Question 264

Eczema herpeticum

Answer 264

- form of primary herpes simplex virus infection associated w/ atopic dermatitis - numerous vesicles over the area of atopic dermatitis are typical - the infection can be life-threatening in infants; thus, prompt tx with acyclovir should be initiated

Question 265

Varicella

Answer 265

-vesicular eruption that is not localized, but tends to spread over the head and to the trunk

Question 266

Impetigo contagiosa

Answer 266

-manifests as thick-crusted facial lesions that are frequently honey-colored

Question 267

The 13-valent pneumococcal conjugate vaccine (PCV13) is recommended for all adults age > 65 followed by the 23-valent pneumococcal polysaccharide vaccine (PPSV23) 6-12 months later. Sequential PCV13 and PPSV23 are also recommended for adults age

Answer 267

.

Question 268

Histoplasma

Answer 268

- usually causes an asymptomatic or minor respiratory illness in healthy pts, but immunocompromised pts can develop severe pulmonary or disseminated disease - the most rapid and sensitive test to diagnose disseminated histoplasmosis in immunocompromised pts is urine or serum assay for Histoplasma antigen - disseminated disease typically presents w/ systemic symptoms and involves the reticuloendothelial system, resutling in cytopenias, lymphadenopathy, and hepatosplenomegaly.

Question 269

treatment for histoplasmosis?

Answer 269

- mild to moderate: no treatment or oral itraconazole | - severe: amphotericin B (switche to oral itraconazole once initial response is documented

Question 270

Flucytosine

Answer 270

-anti-fungal effective against Cryptococcus and Candida

Question 271

Metronidazole

Answer 271

-effective against amebiasis and other anaerobic bacterial infections

Question 272

what is the preferred antifungal tx for histoplasmosis?

Answer 272

Itraconazole

Question 273

Diagnostic criteria for ADHD

Answer 273

- 6 or more inattentive and/or 6 or more hyperactive/impulsive symptoms for 6 or more months - several symptoms present before age 12 - symptoms occur in at least 2 settings - functional impairment (social, academic) - subtypes: predominantly inattentive, predominantly hyperactive/impulsive, combined type

Question 274

By age 12 months, a child's weight and height should...?

Answer 274

- weight should triple; height should increase by 50% - developmental milestones include walking independently, using a 2-finger pincer grasp, saying a few words other than "mama" and "dada", and imitating the actions of others.

Question 275

UTI antibiotics in pregnancy

Answer 275

- recommended: nitrofurantoin, amoxicillin, amoxicillin-clavulanate, cephalexin - contraindicated: tetracylines (interfere with fetal bone and tooth development), fluoroquinolones (bone deformities and arthropathy), TMP-SMX (contraindicated in first trimester as it interferes w/ folic acid metabolism, should be avoided during third trimester as it increases the risk of kernicterus in the newborn) - pregnant women w/ asymptomatic bacteriuria should be treated w/ antibiotics to decrease the risk of pyelonephritis, preterm birth, low birth weight, and perinatal mortality.

Question 276

Cardiac output/index, SVR, and LVEDV in CHF?

Answer 276

-CHF due to left ventricular systolic dysfunction is characterized by decreased cardiac output/index, increased systemic vascular resistance (SVR), and an increase in left ventricular end-diastolic volume (LVEDV)

Question 277

cardiac index/output, SVR, and LVEDV after acute or recent myocardial infarction?

Answer 277

-Cardiac index is reduced due to myocardial dysfunction, while SVR is increased to maintain vital organ perfusion; LVEDV remains relatively normal in the early phase before LV remodeling and/or dilatation occurs over the following several weeks

Question 278

Cardiac index/output, SVR, and LVEDV in high-output CHF (severe anemia, thyrotoxicosis, aortic regurgitation)

Answer 278

-increased LVEDV, decreased SVR, normal/increased CI

Question 279

Placental abruption

Answer 279

- laboring pts w/ placental abruption at term may be allowed to deliver vaginally if the woman and fetus are stable - Cesarean delivery is indicated if the mother is hypotensive w/ severe bleeding or if the condition of the fetus deteriorates - presents as vaginal bleeding and hyperactive and tender uterus - bleeding between the decidua and placenta interface causes placental detachment, which can compromise the fetus - US should be performed to rule out placenta previa (contraindication to vaginal delivery), but it detects only 25% of cases of abruption - laboring patients > 34 WEEKS GESTATION CAN PROCEED TOWARD VAGINAL DELIVERY

Question 280

Placental abruption overview

Answer 280

- risk factors: maternal HTN or preeclampsia/eclampsia, abdominal trauma, prior placental abruption, cocaine and tobacco use - presenation: sudden-onset vaginal bleeding, abdominal or back pain, high-frequency and low-intensity contractions, hypertonic tender uterus - diagnosis: clinical presentation, US (not required for diagnosis) to rule out placenta previa - Tx: unstable maternal VS or nonreassuring fetal heart tracing at any gestational age means emergent C-section; stable maternal VS, reassuring fetal heart tracing, no placenta previa and >34 wks gestation means a trial of vaginal delivery

Question 281

full term

Answer 281

> 37 weeks

Question 282

Kleihauer-Betke test

Answer 282

- used to measure the amount of fetal hemoglobin transferred into the maternal bloodstream - it should be performed on an Rh-negative woman w/ an Rh-positive fetus to determine the dose of Rh immune globulin to prevent Rh sensitization

Question 283

management of suspected bacterial meningitis in adult

Answer 283

- empiric abx must NOT be delayed while awaiting results of CT scan or performing LP to diagnose bacterial meningitis - VANCOMYCIN plus AMPICILLIN plus CEFEPIME is the drug regimen of choice for immunocompromised pts w/ suspected bacterial meningitis - Corticosteroids must be started at the same time as abx and should be discontinued if cultures show an organism other than Strep pneumoniae

Question 284

evaluation of bacterial meningitis

Answer 284

- head CT, blood cultures, LP - indications for head CT: immunocompromised, previous CNS disease, new onset seizure, papilledema, altered mental status, focal neuro deficits

Question 285

bacterial meningitis in 2-50 year olds

Answer 285

- most commonly N. meningitidis, S. pneumoniae | - give Vancomycin plus a 3rd generation cephalosporin

Question 286

bacterial meningitis in age > 50

Answer 286

- S. pneumoniae, N. meningitidis, Listeria | - Vancomycin plus ampicillin plus a 3rd gen cephalosporin

Question 287

bacterial meningitis in neurosurgery/shunt patient

Answer 287

- gram negative rods, S. aureus, and coagulase-negative Staph - Vancomycin plus cefepime

Question 288

Bacterial meningitis in immunocompromised state

Answer 288

- Pneumococcus, N. meningitidis, Listeria, gram negative rods - Vancomycin plus ampicillin plus cefepime

Question 289

Bacterial meningitis in penetrating trauma to skull

Answer 289

- S. aureus, coagulase-negative Staph, and gram negative rods - Vancomycin plus cefepime

Question 290

what leads on ECG do you look at for axis deviation evaluation?

Answer 290

lead 1 lead aVF -if up in 1 and up in aVF, then its a normal axis -axis deviation can be a sign of ventricular hypertrophy or bundle branch block

Question 291

how to evaluate ECG?

Answer 291

-rate, rhythm, axis, intervals, ischemia, and hypertrophy

Question 292

normal intervals on ECG?

Answer 292

- PR interval: 120-200 msec; in AV block PR interval > 200 msec or there will be no QRS after a P wave - QRS interval: 120msec; LBBB has deep S wave and no R wave in V1, and a wide/tall R waves in 1, V5, V6; RBBB has RSR' ("rabbit ears") complex w/ wide R wave in V1 and wide S wave in V5, V6. - QT interval: 440 msec, and predispose to ventricular tachyarrhythmias

Question 293

what leads do you look at on ECG for bundle branch blocks?

Answer 293

V1 and V5/V6 | -WiLLiaM MaRRoW

Question 294

signs of ischemia/infarction on ECG?

Answer 294

- T wave inversion --> ST segment changes (elevation or depression) -- Q waves (> 40 msec or more than 1/3 the QRS amplitude; note that Q waves signify either an acute or prior ischemic event and do NOT give info on when the event occurred - poor R wave progression; on normal ECG, R waves increase in size from V1 through V5

Question 295

signs of hypertrophy on ECG?

Answer 295

- Right atrial hypertrophy: tall P wave in lead II (>2.5 mm) - Left atrial hypertrophy: wide P wave in lead II (>120 msec); notched P waves are frequently seen (cameL has Left atrial enlargement) - LVH: S wave amplitude in V1 + R wave amplitude in V5/V6 = > 35 mm; alternatively, amplitude of R in aVL + S in V3 is > 28 mm in men or > 20 mm in women - RVH: Right axis deviation and an R wave in V1 > 7 mm

Question 296

what conditions is Kussmaul sign seen?

Answer 296

- Cardiac tamponade and constrictive pericarditis | - Increase in JVP w/ inspiration is Kussmaul sign

Question 297

harsh systolic ejection murmur that radiates to the carotids?

Answer 297

aortic stenosis

Question 298

holosystolic murmur that radiates to the axilla

Answer 298

mitral regurgitation

Question 299

a midsystolic click or late systolic murmur with a preceding click

Answer 299

mitral valve prolapse

Question 300

Diastolic murmurs are ALWAYS ABNORMAL!

Answer 300

.

Question 301

an early decrescendo murmur

Answer 301

-aortic regurgitation

Question 302

a mid to late, low-pitched murmur

Answer 302

-mitral stenosis

Question 303

S3 gallop

Answer 303

- sign of fluid overload | - often normal in younger pts and in high-output states (eg pregnancy)

Question 304

S4 gallop

Answer 304

- sign of decreased compliance (ie HTN, diastolic dysfunction) - usually pathologic but can be normal in younger pts and athletes

Question 305

things that can cause peripheral edema

Answer 305

-right heart failure, biventricular failure, nephrotic syndrome, hepatic disease, lymphedema, hypoalbuminemia, and drugs

Question 306

pulsus paradoxus

Answer 306

- decreased SBP w/ inspiration - possible sign of Pericardial tamponade; also seen in obstructive lung disease, tension pneumothorax, and foreign body in airway

Question 307

increased peripheral pulses

Answer 307

-compensated aortic regurgitation (bounding pulses), coaractation (greater in arms than legs), PDA

Question 308

pulsus alternans

Answer 308

- alternating weak and strong pulses | - cardiac tamponade, impaired left ventricular systolic function; poor prognosis

Question 309

pulsus parvus et tardus

Answer 309

- weak and delayed pulse | - aortic stenosis!

Question 310

management options for atrial fibrillation

Answer 310

ABCD - anticoagulate - B blockers for rate control!! - cardiovert/calcium channel blockers - Digoxin (in refractory cases)

Question 311

opening snap followed by a mid diastolic murmur

Answer 311

mitral stenosis

Question 312

machine-like murmur

Answer 312

PDA

Question 313

CHA2DS2-VASc score

Answer 313

- used to estimate stroke risk in pt w/ atrial fibrillation; anticoagulate if score is > 2 - CHF (1 point) - HTN (1 point) - Age > 75 (2 points) - Diabetes (1 point) - Stroke or TIA hx (2 points) - Vascular disease (1 point) - Age 65-74 (1 point) - Sex category (female; 1 point)

Question 314

first degree AV block

Answer 314

- can occur in normal individuals; associated w/ increased vagal tone and w/ B-blocker or CCB use - asymptomatic - PR interval > 200 msec - no treatment necessary

Question 315

Second degree AV block (Mobitz type 1/Wenckebach)

Answer 315

- drug effects (digoxin, B-blockers, CCBs) or increased vagal tone; right coronary ischemia or infarction - usually asymptomatic - progressive PR lengthening until a dropped beat occurs; the PR interval then resets - Tx: stop offending drug; Atropine as indicated

Question 316

Second degree AV block (Mobitz type II)

Answer 316

- results from fibrotic disease of the conduction system or from acute, subacute, or prior MI - occasonally syncope; frequent progression to third-degree AV block!!!! - unexpected dropped beat(s) without a change in PR interval - Tx is PACEMAKER PLACEMENT

Question 317

Third degree AV block (complete)

Answer 317

- no electrical communication between the atria and ventricles - syncope, dizziness, acute heart failure, hypotension, cannon A waves - no relationship between P waves and QRS complexes - Tx is PACEMAKER PLACEMENT

Question 318

Sick sinus syndrome/ tachycardia-bradycardia syndrome

Answer 318

- a heterogeneous disorder that leads to intermittent supraventricular tachyarrhythmias and bradyarrhythmias - secondary to tachycardia or bradycardia; may include syncope, palpitations, dyspnea, chest pain, TIA, and stroke - this is the MOST COMMON INDICATION FOR PACEMAKER PLACEMENT

Question 319

drug used to treat Wolff-Parkinson-White syndrome?

Answer 319

Procainamide

Question 320

Atrial fibrillation

Answer 320

- acute AF: PIRATES: Pulmonary disease, Ischemia, Rheumatic heart disease, Anemia/Atrial myxoma, Thyrotoxicosis, Ethanol, Sepsis. - chronic AF: HTN, CHF - often asymptomatic but may present w/ SOB, chest pain, or palpitations; physical exam shows an IRREGULARLY IRREGULAR pulse - no discernable P waves w/ variable and irregular QRS response - for chronic AF, initial therapy: RATE CONTROL WITH B-BLOCKERS, CCB, or Digoxin; Anticoagulate w/ warfarin for pts w/ CHADS-VASc > 2; for unstable AF, or new-onset AF ( 2 days or unclear duration, must get TEE to rule out atrial clot!!!!

Question 321

atrial flutter

Answer 321

- circular movement of electrical activity around the atrium at a rate of approx. 300 times per minute - usually asymptomatic but can present w/ palpitations, syncope, and lightheadedness - regular rhythm; "SAWTOOTH" APPEARANCE OF P WAVES; atrial rate is usually between 240-320 bpm and ventricular rate is about 150 bpm. - Tx: anticoagulation, rate control, and cardioversion as in atrial fibrillation

Question 322

multifocal atrial tachycardia

Answer 322

- multiple atrial pacemakers or reentrant pathways; COPD, hypoxemia - may be asymptomatic; at least 3 DIFFERENT P WAVE MORPHOLOGIES - three or more unique P waves, rate > 100 bpm - treat the underlying disorder; verapamil or B-blockers for rate control and suppression of atrial pacemakers (not very effective)

Question 323

AVNRT

Answer 323

- a reentry circuit in the AV node depolarizes the atrium and ventricle nearly simultaneously - occurs at AV junction - rate 150-250 bpm; P WAVE IS OFTEN BURIED in QRS or shortly after - Tx: cardiovert if hemodynamically unstable; carotid massage, valsalva, or adenosine can stop the arrhythmia

Question 324

AVRT

Answer 324

- occurs at AV junction - an ectopic connection between the atrium and ventricle that causes a reentry circuit; seen in WPW - a retrograde P wave is often seen after a normal QRS; PREEXCITATION DELTA WAVE IS CHARACTERISTICALLY SEEN IN WPW - cardiovert, valgal maneuvers, adenosine

Question 325

Paroxysmal atrial tachycardia

Answer 325

- rapid ectopic pacemaker in the atrium (not sinus node) - rate > 100 bpm; P wve w/ an unusual axis BEFORE each normal QRS - Tx: adenosine can be used to unmask underlying atrial activity by slowing down the rate

Question 326

PVCs

Answer 326

- ectopic beats arise from ventricular foci; associated w/ hypoxia, electrolyte abnormalities, and hyperthyroidism - early, wide QRS not preceded by a P wave; PVCs are usually followed by a compensatory pause - Treat the underlying cause; if symptomatic, give B-blockers

Question 327

Wolff-Parkinson-White syndrome

Answer 327

- abnormal fast accessory pathway from atria to ventricle - characteristic DELTA WAVE w/ widened QRS complex and shortened PR interval - tx is observation for asymptomatic pts

Question 328

Ventricular tachycardia

Answer 328

- can be associated w/ CAD, MI, and structural heart disease - can progress to VF and death - 3 or more consecutive PVCs; wide QRS complexes in a regular rapid rhythm; may see AV dissociation - cardioversion if unstable; antiarrhythmics (amiodarone, lidocaine, procainamide)

Question 329

Ventricular fibrillation

Answer 329

- totally erratic wide-complex tracing | - immediate electrical defibrillation and ACLS protocol!

Question 330

Torsades de pointes

Answer 330

- associated w/ long QT syndrome, proarrhythmic response to meds, hypokalemia, congenital deafness, and alcoholism - polymorphous QRS; VT w/ rates between 150 - 250 bpm - give MAGNESIUM initially and cardiovert if unstable; correct underlying disorder

Question 331

use of diuretic and digoxin in CHF?

Answer 331

-used for symptomatic relief only and confer NO mortality benefit

Question 332

most common presenting symptoms of systolic dysfunction?

Answer 332

-exertional dyspnea

Question 333

lab abnormality in CHF?

Answer 333

- brain natriuretic peptide (BNP) > 500 pg/mL | - decreased EF

Question 334

Acute treatment of CHF?

Answer 334

- Loop diuretics (most commonly; Lasix)for aggressive diuresis - Morphine - Nitrates - Oxygen - Position (upright) - LMNOP - AVOID B-BLOCKERS IN DECOMPENSATED CHF, but resume once euvolemic

Question 335

chronic treatment of CHF?

Answer 335

- lifestlye: limit dietary sodium and fluid intake - meds: b-blockers and ACEIs/ARBs (help prevent remodeling of the heart and decrease mortality; avoid CCBs!). Diuretics prevent volume overload. Low-dose spironolactone has been shown to decrease mortality w/ advanced heart failure. Daily aspirin and a statin if underlying cause was prior MI - advanced tx: implantable cardiac defibrillator if EF

Question 336

Loop diuretics Lose calcium; thiazides take it in

Answer 336

.

Question 337

Diastolic dysfunction/ nonsystolic dysfunction

Answer 337

- decreased ventricular compliance w/ normal systolic function - ventricle either has IMPAIRED ACTIVE RELAXATION or IMPAIRED PASSIVE FILLING - LVEDP is increased, cardiac output remain normal, and EF IS NORMAL OR INCREASED

Question 338

Loop diuretics

Answer 338

- Furosemide (Lasix), ethacrynic acid, bumetanide, torsemide | - side effects: ototoxicity, HYPOKALEMIA, HYPOCALCEMIA, dehydration, gout

Question 339

Thiazide diuretics

Answer 339

- HYDROCHLOROTHIAZIDE, chlorothiazide, chlorthalidone - side effects: hypokalemic metabolic alkalosis, hyponatremia, and hyperGLUC (hyperGlycemia, hyperLipidemia, hyperUricemia, hyperCalcemia)

Question 340

potassium sparing diuretics

Answer 340

- SPIRONOLACTONE, triamterene, amiloride | - side effects: hyperkalemia, gynecomastia, sexual dysfunction

Question 341

Carbonic anhydrase inhibitors as diuretics

Answer 341

- Acetazolamide | - side effects: hyperchloremic metabolic acidosis, neuropathy, NH3 toxicity, sulfa allergy

Question 342

Osmotic agents as diuretics

Answer 342

- Mannitol | - side effects: pulmonary edema, dehydration; contraindicated in anuria and CHF

Question 343

dilated cardiomyopathy

Answer 343

- left ventricular dilation and decreased EF must be present - most cases are idiopathic; most common secondary causes are ischemia and long-standing HTN; also coxsackievirus, Chagas disease are rare - ECHO is diagnostic - an S3 gallop signifies rapid ventricular filling in the setting of fluid overload and is associated with dilated cardiomyopathy

Question 344

Differentiate between dilated, hypertrophic, and restrictive cardiomyopathies

Answer 344

- Dilated: impaired contractility, increase LVEDV, increased LVESV, decreased EF, and usually decreased wall thickness - Hypertrophic: impaired relaxation, decreased LVEDV, decreased LVESV, increased or normal EF, markedly increased wall thickness - Restrictive: impaired elasticity, increased LVEDV, increased LVESV, decreased or normal EF, usually increased wall thickness

Question 345

most common cause of sudden death in young athletes?

Answer 345

hypertrophic obstructive cardiomyopathy - inherited as an autosomal dominant trait - key finding is a systolic ejection crescendo-decrescendo murmur that increases with decreased preload - Echo is diagnostic and shows an asymmetrically thickened septum and dynamic obstruction of blood flow - Tx: B-blockers are initial therapy; CCB are second-line; avoid intense athletic competition and training

Question 346

Restrictive cardiomyopathy

Answer 346

- decreased elasticity of myocardium leading to impaired diastolic filling w/o significant systolic dysfunction; caused by INFILTRATIVE DISEASE (amyloidosis, sarcoidosis, hemochromatosis) or by scarring and fibrosis - right sided heart failure symptoms often predominate - echo is diagnostic, w/ rapid early filling and a near-normal EF - ECG frequently shows LBBB; low voltages are seen in amyloidosis - Tx: generally palliative only; cautious use of diuretics for fluid overload and vasodilators to decrease filling pressure

Question 347

Prinzmetal (variant) angina

Answer 347

-mimics angina pectoris but is caused by vasospasm of coronary vessels; classically affects young women at rest in the early morning and is associated w/ ST segment elevation in the absence of cardiac enzyme elevation

Question 348

angina pectoris

Answer 348

- substernal chest pain secondary to myocardial ischemia - classic triad: substernal chest pain, precipitated by stress, relieved by rest - pain can radiate to neck or arm or associated with SOB, N/V, diaphoresis, or lightheadedness; pain is usually dull and pressure-like - ECG is best initial test for any type of chest pain (ECG stress test is contraindicated for pts w/ abnormal baseline ECGs)

Question 349

Differential diagnosis of chest pain

Answer 349

- cardiac origin - GERD (hx of hoarseness and worse after meals; relief w/ PPIs) - MSK/costochondritis (pain is tender to palpation and movement) - Pneumonia/pleuritis (worsening w/ breathing (pleuritic)) - Anxiety (hx of panic disorder or anxiety attacks)

Question 350

Tx for chronic stable angina

Answer 350

- aspirin, b-blockers, and nitroglycerin | - risk factor reduction (smoking, cholesterol, HTN)

Question 351

unstable angina vs NSTEMI

Answer 351

- unstable angina: new onset, accelerating, or occurring at rest; signals impending infarction based on plaque instability - NSTEMI: myocardial necrosis marked by elevations in troponin I and CKMB - Unstable angina is NOT associated w/ elevated cardiac enzymes; NSTEMI is diagnosed by serial cardiac enzymes (elevated) and ECG - Tx: aspirin, oxygen, IV nitro, IV morphine, B-blockers - admit to hospital and monitor until acute MI has been ruled out by serial cardiac enzymes - Pts w/ refractory chest pain, a TIMI score of > 3, a troponin elevation, or ST changes > 1 mm should be given IV heparin and scheduled for angiography and possible PCI or CABG

Question 352

TIMI risk score for unstable angina/NSTEMI

Answer 352

- age > 65 (1 point) - 3 or more CAD risk factors (premature family hx, DM, smoking, HTN, increased cholesterol) (1 point) - known CAD (stenosis > 50 %) (1 point) - ASA use in past 7 days (1 point) - severe angina (2 or more episodes within 24 hours) (1 point) - ST deviation > 0.5 mm (1 point) - + cardiac marker (1 point) - scale from 0-7; pts at higher risk 3 or more points benefit from enoxaparin, glycoprotein IIb/IIIa inhibitors, and early angiography

Question 353

best predictor of survival in STEMI?

Answer 353

LV ejection fraction

Question 354

Treatment of MI

Answer 354

- MOAN - Morphine - Oxygen - ASA - Nitro

Question 355

Remember that women, diabetics, the elderly, and post-transplant heart pts may have atypical or clinically silent MIs

Answer 355

.

Question 356

most sensitive and specific cardiac enzyme

Answer 356

- Troponin I | - stays elevated longer than CK-MB

Question 357

ST-segment abnormalities on ECG with Inferior, Anterior, Lateral, and Posterior MIs

Answer 357

- Inferior MI: involving RCA/PDA, ST elevation in leads II, III, and aVF; obtain a right-sided ECG to look for ST elevation in right ventricle! - Anterior MI: involving LAD and diagonal branches; ST elevation in leads V1-V4 - Lateral MI: involving LCA; ST elevation in leads I, aVL, and V5-V6 - Posterior MI: ST depression in V1-V2 (anterior leads); obtain posterior ECG leads V7-V9

Question 358

initial tx of STEMI

Answer 358

- ASA, b-blockers (unless in heart failure or cardiogenic shock; instead give ACEIs if not hypotensive), clopidogrel, morphine, nitrates, and oxygen - in inferior wall MI, avoid nitrates due to risk of severe hypotension

Question 359

Emergent angiography and PCI vs thrombolysis

Answer 359

-If PCI cannot be performed within 90 minutes, AND there are no contraindications to thrombolysis (eg a hx of hemorrhagic stroke, or recent ischemic stroke, severe heart failure, or cardiogenic shock), AND the pt presents within 3 hrs of chest pain onset, thrombolysis w/ tPA, reteplase, or streptokinase should be performed instead of PCI

Question 360

common post-MI complications

Answer 360

- first day: heart failure - 2-4 days: arrhythmia, pericarditis - 5-10 days: left ventricular wall rupture (acute pericardial tamponade causing electrical alternans, pulseless electrical activity), papillary muscle rupture (severe mitral regurgitation) - weeks to months: ventricular aneurysm (CHF, arrhythmia, persistent ST segment elevation, mitral regurgitation, thrombus formation) - Dressler syndrome: an autoimmune process occurring 2-10 wks post-MI, presents w/ fever, pericarditis, pleural effusion, leukocytosis, and elevated ESR

Question 361

dyslipidemia

Answer 361

- total cholesterol > 200 mg/dL - LDL > 130 mg/dL - Triglycerides > 150 mg/dL - HDL 35 years of age or > 20 w/ CAD risk factors, then every 5 yrs. - Tx: hx of CAD, CVA, or PAD --> high intensity statin; LDL between 70-189 WITHOUT diabetes (>7.5% 10 yr risk--> high intensity statin; between 5-7.5% 10 yr risk--> moderate intensity statin; no statin); LDL between 70-189 WITH diabetes (>7.5% 10 yr risk--> high intensity statin; moderate intensity statin); for pts w/ LDL > 190--> high intensity statin - high intensity therapy is a goal reduction of > 50% LDL; moderate intensity is reduction of 30-50% LDL - first intervention should be a 12 week trial of diet and exercise

Question 362

Statins

Answer 362

- decrease LDL | - decrease triglycerides

Question 363

Fibrates (gemfibrozil)

Answer 363

- decrease triglycerides | - increase HDL

Question 364

cholesterol absorption inhibitors (ezetimibe)

Answer 364

-decrease LDL

Question 365

Niacin

Answer 365

- increase HDL - decrease LDL - causes skin flushing which can be prevented with aspirin ingestion

Question 366

bile acid resins (cholestyramine)

Answer 366

- decrease LDL | - can decrease absorption of other drugs in GI tract

Question 367

HTN definition

Answer 367

- SBP > 140, and/or DBP > 90 on 3 measurements separated in time in pts 60, SBP > 150 and/or DBP > 90 (if no hx of CKD, DM) - pts > 18 yrs w/ CKD or DM, SBP > 140 and/or DBP > 90 - you will initiate treatment above any of these variables for these populations

Question 368

Treatment of HTN

Answer 368

ABCD - ACEIs/ARBs - B-blockers - CCBs - Diuretics (typically thiazides)

Question 369

treatment of HTN in pregnancy

Answer 369

-b-blockers (typically labetalol), hydralazine

Question 370

tx of HTN in CKD

Answer 370

ACEIs, ARBs

Question 371

Hypertensive urgency

Answer 371

-elevated BP with MILD TO MODERATE SYMPTOMS (headache, chest pain) WITHOUT end-organ damage

Question 372

Hypertensive Emergency

Answer 372

- elevated BP w/ signs or symptoms of impending end-organ damage such as acute kidney injury, intracranial hemorrhage, papilledema, or ECG changes suggestive of ischemia or pulmonary edema - tx w/ IV meds (labetalol, nitroprusside, nicardipine) w/ goal of lowering MAP by no more than 25% over the fist 2 hours to prevent cerebral hypoperfusion or coronary insufficiency

Question 373

Tx of pheochromocytoma

Answer 373

- Diagnose w/ urinary metanephrines and catecholamine levels or plasma metanephrine - surgical removal of tumor after treatment with BOTH A-BLOCKERS AND B-BLOCKERS

Question 374

Conn syndrome (hyperaldosteronism)

Answer 374

- most often secondary to an aldosterone-producing adrenal adenoma - causes the triad of HTN, unexplained hypokalemia, and metabolic alkalosis - metabolic workup w/ plasma aldosterone and renin levels; increase aldosterone and decreased renin levels suggest primary hyperaldosteronism; surgical removal of tumor

Question 375

Cushing syndrome

Answer 375

- due to ACTH producing pituitary tumor, an ectopic ACTH secreting tumor, or cortisol secretion by an adrenal adenoma or carcinoma; also due to exogenous steroid exposure - tx is surgical removal of tumor; removal of exogenous steroids

Question 376

Causes of pericarditis

Answer 376

CARDIAC RIND - Collagen vascular disease - Aortic dissection - Radiation - Drugs - Infections - Acute renal failure - Cardiac (MI) - Rheumatic fever - Injury - Neoplasma - Dressler syndrome - viral infection, TB, SLE, uremia, drugs, radiation, neoplasms, post-MI or Dressler's

Question 377

classic presentation of pericarditis

Answer 377

- pleuritic chest pain, dyspnea, cough, fever - chest pain tends to WORSEN IN THE SUPINE POSITION, and with inspiration; classic patient is SEEN SITTING UP AND BENDING FORWARD - may hear pericardial friction rub on exam, elevated JVP, pulsus paradoxus (a decrease in SBP > 10mmHg on inspiration) if tamponade present - ECG will show DIFFUSE ST-SEGMENT ELEVATION AND PR-SEGMENT DEPRESSIONS, followed by T wave inversions

Question 378

B-blockers

Answer 378

- decrease cardiac contractility and renin release | - side effects: bronchospasm (in severe active asthma), bradycardia, CHF exacerbation, impotence, fatigue, depression

Question 379

ACEIs

Answer 379

- block aldosterone formation, reducing peripheral resistance and salt/water retention - side effects: cough, angioedema, rahes, leukopenia, hyperkalemia

Question 380

ARBs

Answer 380

- sartan - block aldosterone EFFECTS, reducing peripheral resistance and salt/water retention - side effects: rashes, leukopenia, and hyperkalemia but NO COUGH

Question 381

Caclium channel blockers

Answer 381

- Dihydropyridines (nifedipine, felodipine, amlodipine), and Nondihydropyridines (diltiazem, verapamil) - decrease smooth muscle tone and cause vasodilation; may also decrease cardiac output - Dihydropyridines: headache, flushing, peripheral edema - Nondihydropyridines: decreased contractility

Question 382

Vasodilators

Answer 382

- Hydralazine: headache, lupus-like syndrome - Minoxidil: orthostasis, hirsutism - decrease peripheral resistance by dilating arteries/arterioles

Question 383

a1-adrenergic blockers

Answer 383

- prazosin, terazosin, phenoxybenzamine - cause vasodilation by blocking actions of norepinephrine on vascular smooth muscle - side effects: orthostatic hypotension

Question 384

centrally acting adrenergic agonists

Answer 384

- methyldopa, clonidine - inhibit the sympathetic nervous system via central a2 adrenergic receptors - side effects: somnolence, orthostatic hypotension, impotence, rebound HTN

Question 385

exam of a patient w/ acute tamponade

Answer 385

- Beck triad (hypotension, distant heart sounds, JVD), a narrow pulse pressure, pulsus paradoxus, and Kussmaul sign (increased JVD on inspiration) - CXR will show enlarged, globular, water-bottle shaped heart - ECG could show ELECTRICAL ALTERNANS, which is diagnostic

Question 386

S1Q3T3 on ECG?

Answer 386

Pulmonary embolism

Question 387

size of AAA determines treatment

Answer 387

> 5 cm--> surgical repair | monitoring

Question 388

Screening for AAA?

Answer 388

-screen all men 65-75 years of age w/ a hx of smoking once by US

Question 389

classic exam finding for aortic stenosis?

Answer 389

Pulsus parvus et tardus (weak, delayed carotid upstroke) | -also, systolic murmur radiating to the carotids

Question 390

exam findings with aortic regurgitation

Answer 390

- blowing diastolic murmur at left sternal border, mid-diastolic rumble (Austin Flint murmur), and midsystolic apical murmur - WIDENED PULSE PRESSURE causes de Musset sign (head bob w/ heartbeat), Corrigan sign (water-hammer pulse), and Duroziez sign (femoral bruit)

Question 391

Dissections involving the ASCENDING aorta are surgical emergencies! Those involving the DESCENDING aorta can often be managed w/ BP and heart rate control

Answer 391

.

Question 392

Virchow triad

Answer 392

- hemostasis - trauma (endothelial damage) - hypercoagulability

Question 393

Treatment for DVT?

Answer 393

anticoagulate w/ IV unfractionated heparin or subcutaneous LMWH followed by PO warfarin for a total of 3-6 months

Question 394

Diagnosis of PAD

Answer 394

-get and ABI; if

Question 395

Orthostatic hypotension

Answer 395

-drop in SBP > 20 mmHg when moving from lying down to standing and is typically preceded by a lightheaded or presyncopal sensation

Question 396

All pts w/ hypotension/shock after a MVA should be presumed to have hypovolemic shock from hemorrhage. An elevated pulmonary capillary wedge pressure at baseline should raise the suspicion of myocardial dysfunction due to cardiac contusion and prompt an urgent echocardiogram.

Answer 396

.

Question 397

High-energy, blunt, rapid deceleration trauma to the chest commonly causes aortic injury. In most cases of aortic rupture, death is the immediate result. In pts w/ a contained rupture, the diagnosis must be made quickly. Widened mediastinum and left-sided hemothorax are classic chest x-ray abnormalities pointing to this diagnosis.

Answer 397

.

Question 398

esophageal rupture

Answer 398

- causes pneumomediastinum and pleural effusion | - diagnosis confirmed w/ water-soluble contrast esophagography

Question 399

bronchial rupture

Answer 399

-pneumothorax that does not resolve w/ chest tube placement, pneumomediastinum and subcutaneous emphysema

Question 400

Wolff-Parkinson-White syndrome

Answer 400

- pts w/ WPW who develop atrial fibrillation w/ a rapid ventricular rate should be treated w/ cardioversion if hemodynamically unstable, or antiarrhythmics such as PROCAINAMIDE or ibutilide if stable. AV nodal blockers such as beta blockers, calcium channel blockers, digoxin, and adenosine should be avoided as they can cause increased conduction through the accessory pathway!! - accessory pathway conducts depolarization directly from atria to ventricles w/o traversing the AV node

Question 401

Acute type A aortic dissection

Answer 401

- type A involves the ascending aorta and is a SURGICAL EMERGENCY; all other locations are type B - type A can extend into the pericardial space, causing hemopericardium and rapidly progressing to cardiac tamponade and cardiogenic shock - bedside TEE is typically performed in the ED for rapid diagnosis and early treatment!!

Question 402

aortic dissection

Answer 402

- risk factors: HTN (most common), Marfan syndrome, cocaine use - features: severe, sharp, tearing chest or back pain; > 20 mmHg variation in SBP between arms - complications (involved structure): Stroke (carotids), acute aortic regurgitation (aortic valves), Horner's syndrome (superior cervical sympathetic ganglion), acute MI (coronary artery), pericardial effusion/tamponade (pericardial cavity), hemothorax (pleural cavity), lower extremity weakness (spinal or common iliac arteries), abdominal pain (mesenteric artery)

Question 403

all pts who have had a MI should receive secondary prevention. Which meds have been shown to have a mortality benefit when given as secondary prevention?

Answer 403

- aspirin (75-325 mg/day) - beta-blockers - ACE inhibitors - lipid lowering statin drugs -in addition, CLOPIDOGREL should be given to all pts w/ unstable angina/NSTEMI, as well as pts who are post percutaneous coronary intervention (PCI)

Question 404

Clopidogrel

Answer 404

- should be given to all pts w/ unstable angina/NSTEMI, as well as those having had a PCI - belongs to drug class called Thienopyridines, and has an anti-platelet effect by antagonizing ADP - for pts who need to be on aspirin but cannot tolerate it, clopidogrel is an appropriate alternative because it is as effective - for pts who are post UA/NSTEMI, clopidogrel + aspirin has been shown to be more effective in terms of mortality than aspirin alone. Clopidogrel should be taken for 12 months, aspirin indefinitely. - clopidogrel + aspirin is more effective than aspirin alone for the first 30 days following PCI as it helps prevent subacute stent thrombosis - basically, clopidogrel should be prescribed for at least 12 months following UA/NSTEMI, 30 days for bare metal stents, and up to 1 year for drug eluting stents following PCI

Question 405

Amiodarone

Answer 405

- class III antiarrhythmic agent, well known for causing pulmonary fibrosis - thyroid dysfunction (hypo and hyper), hepatotoxicity, corneal deposits and skin discoloration (blue-gray) are other potential side effects - excellent drug for BOTH atrial and ventricular arrhythmias

Question 406

Procainamide

Answer 406

- used to treat atrial AND ventricular arrhythmias | - side effects: nausea, drug-induced lupus, agranulocytosis, and QT prolongation

Question 407

Lidocaine

Answer 407

- class IB anti-arrhythmic agent use to treat VENTRICULAR arrhythmias - high doses can cause confusion, seizures and respiratory depression

Question 408

Quinidine

Answer 408

- class IA anti-arrhythmic used to treat ATRIAL arrhythmias | - side effects: diarrhea, tinnitus, QT prolongation, torsades de pointes, hemolytic anemia and thrombocytopenia

Question 409

Digoxin

Answer 409

- inotrope used to treat ATRIAL arrhythmias | - can cause nausea, anorexia, AV block, and ventricular and supraventricular arrhythmias

Question 410

Chagas disease

Answer 410

- chronic disease that can cause megaesophagus, megacolon, and/or cardiac dysfunction - the PROTOZOAN Trypanosoma cruzi, endemic to Latin America, is responsible

Question 411

Don't give beta blockers to cocaine-using individuals, as this allows unopposed alpha agonist activity that can worsen vasospasm. Instead use calcium channel blockers and alpha blockers like phentolamine to help reduce vasospasm.

Answer 411

.

Question 412

Right ventricular myocardial infarction (RVMI)

Answer 412

- presents w/ hypotension, elevated JVP, and clear lung fields in the setting of acute inferior MI - pts require increased RV preload to maintain cardiac output and may need IV fluid support - Nitrates, diuretics, and opioids can reduce RV preload and should be avoided!

Question 413

Situational syncope

Answer 413

- should be considered in differential of syncopal episodes - the typical scenario would be a middle age or older male, who loses his consciousness immediately after urination, or a man who loses his consciousness during coughing fits

Question 414

pulmonary capillary wedge pressure (PCWP)

Answer 414

- estimation of left ventricular end diastolic pressure - elevated in pts w/ left ventricular systolic and/or diastolic dysfunction - elevation typically causes signs of pulmonary edema

Question 415

Cor pulmonale

Answer 415

- impaired function of the right ventricle due to PULMONARY HYPERTENSION that usually occurs due to chronic lung disease - signs of right ventricular failure: elevated JVP, right ventricular 3rd heart sound, tricuspid regurgitation murmur, hepatomegaly w/ pulsatile liver, lower-extremity edema, ascites, and/or pleural effusions - echo will shows signs of increased right heart pressures, and right heart catheterization will show pulmonary systolic pressure > 25 mmHg

Question 416

calcium channel blockers

Answer 416

- dihydropyridine: amlodipine, nimodipine, nifedipine - non-dihydropyridine: diltiazem, verapamil - mechanism: block voltage dependent L-type calcium channels of cardiac and smooth muscle, thereby reduce muscle contractility; - Verapamil is most effective in cardiac muscle (Verapamil = Ventricle) - DHPs (except nimodipine) are used for HTN, angina, Raynaud's - Non-DHPs are used for HTN, angina, ATRIAL FIBRILLATION/FLUTTER - Nimodipine: subarachnoid hemorrhage (prevents cerebral vasospasm) - side effects: cardiac depression, AV block, peripheral edema, flushing, dizziness, hyperprolactinemia, and constipation

Question 417

Digoxin

Answer 417

- cardiac glycoside - mechanism: direct inhibition of Na/K ATPase leads to indirect inhibition of Na/Ca exchanger/antiport. Increased Ca conduction leads to positive inotropy. Stimulates vagus nerve which decreases HR. - used to increase contractility in CHF, and to slow conduction at AV node and SA node in ATRIAL fibrillation - can cause change in color vision, hyperkalema, AV block - antidote is to slowly normalize potassium, cardiac pacer, anti-digoxin Fab fragments, Mg

Question 418

Antiarrhythmics

Answer 418

- Na channel blockers (class 1) - B-blockers (class 2) - potassium channel blockers (class 3) - Calcium channel blockers (class 4) "Some Blokes Possess Cardio"

Question 419

Class 1 anti-arrhythmics (sodium channel blockers)

Answer 419

- slow or block conduction (esp in depolarized cells); decrease slope of phase 0 depolarization and increase threshold for firing in abnormal pacemaker cells; they are state dependent (selectively depress tissue that's frequently depolarized; hyperkalemia causes increased toxicity for all class 1 drugs - Class 1A: Quinidine, Procainamide, Disopyramide ("the Queen Proclaims Diso's Pyramid"); increase AP duration, increase refractory period, increase QT interval; used for BOTH ATRIAL AND VENTRICULAR ARRHYTHMIAS, esp re-entrant and ectopic SVT and VT BOTH ATRIA AND VENTRICLES - Class 1B: Lidocaine, Mexiletine; decrease AP duration; preferentially affect ischemic or depolarized Purkinje and ventricular tissue; used for ACUTE VENTRICULAR ARRHYTHMIAS (esp post-MI), digitalis induced arrhythmias (1B is Best post-MI) VENTRICLES - Class 1C: Flecainide, Propafenone ("Can I have Fries, Please"); significantly prolongs refractory period in AV NODE; minimal effect on AP duration; used for SVTs, INCLUDING ATRIAL FIBRILLATION; contraindicated post-MI!!!!! ATRIA

Question 420

Class 2 anti-arrhythmics (B-blockers)

Answer 420

- Metoprolol, propranolol, esmolol, atenolol, timolol, carvedilol - decrease SA and AV nodal activity by decreasing cAMP, decreasing Ca currents; suppress abnormal pacemakers by decreasing slope of phase 4 - used for SVT, slowing VENTRICULAR rate during a. fib and a. flutter - treat overdose with glucagon

Question 421

Class 3 anti-arrhythmics (Potassium channel blockers)

Answer 421

- Amiodarone, Ibutilide, Dofetilide, Sotalol ("AIDS") - increase AP duration, increase effective refractory period, increase QT interval (all the same as class 1 anti-arrhythmics) - used for ATRIAL FIBRILLATION, ATRIAL FLUTTER, VENTRICULAR TACHYCARDIA (amiodarone, sotalol) - know that amiodarone can cause PULMONARY FIBROSIS, hepatotoxicity, hypo/hyperthyroidism, corneal deposits, skin deposits, etc.; must check PFTs, LFTs, and TFTs when using amiodarone; it also has class I,II,III, and IV effects and alters the LIPID MEMBRANE

Question 422

Class 4 anti-arrhythmics (calcium channel blockers)

Answer 422

- Verapamil, diltiazem - decrease conduction velocity, increase effective refractory period, increase PR interval - used for prevent NODAL ARRHYTHMIAS (eg SVT), rate control in ATRIAL FIBRILLATION - can cause flushing, constipation, edema, AV block, CHF

Question 423

Adenosine

Answer 423

- increase potassium out of cells leads to hyperpolarizing the cell and decrease Ca conductance - drug of choice in DIAGNOSING/ABOLISHING SUPRAVENTRICULAR TACHYCARDIA; very short acting (~15 sec) - may cause flushing, hypotension, chest pain; effects blocked by theophylline and caffeine

Question 424

Mg

Answer 424

-effective in torsades de pointes and DIGOXIN toxicity

Question 425

Anti-arrhythmics used for VENTRICULAR arrhythmias?

Answer 425

Class 1a, 1b (sodium blockers), and class 3 (potassium blockers)

Question 426

anti-arrhythmics for atrial arrhythmias?

Answer 426

-class 1a, 1c (sodium blockers), class 2, class 3

Question 427

Adenosine

Answer 427

-inhibits L-type calcium channels, decreasing conduction velocity in the AV node; this can lead to a transient AN nodal block and is used in the tx of AV node-dependent reentrant tachycardia

Question 428

Complete heart block

Answer 428

- type 3 AV block - temporal dissociation of P waves and QRS complexes (AV dissociation) - pts w/ symptomatic 3rd degree AV block should be managed w/ temporary pacemaker insertion while undergoing further evaluation to identify and correct reversible causes - a permanent pacemaker is indicated if no reversible causes of heart block are found.

Question 429

Antibiotic therapy in pts w/ infective endocarditis

Answer 429

- should be tailored to the specific organism as soon as they are identified (start empiric IV vancomycin first) - most viridans group strep are highly susceptible to penicillin and should be treated w/ IV aqueous penicillin G or IV ceftriaxone for 4 weeks

Question 430

Dihydropyridine Ca-channel blockers most common side effect

Answer 430

-peripheral edema

Question 431

what is the most frequent cause of isolated aortic stenosis in elderly patients?

Answer 431

age-dependent idiopathic sclerocalcific changes | -these changes are common and usually have minimal hemodynamic significance, but sometimes may be severe

Question 432

ECG in pts w/ Wolff-Parkinson-White syndrome

Answer 432

-shortened PR interval, delta waves, and widening of the QRS complex

Question 433

Mitral regurgitation

Answer 433

- holosystolic murmur heard best at the apex w/ radiation to the axilla - exertional dyspnea, fatigue, atrial fibrillation, and signs of heart failure

Question 434

Pts w/ persistent tachyarrhythmia (narrow or wide complex) causing hemodynamic instability should be managed w/ IMMEDIATE SYNCHRONIZED DC CARDIOVERSION. Pts who have minimal symptoms and remain hemodynamically stable during an episode of regular, narrow-complex SVT can be managed initially w/ a trial of vagal maneuvers and/or IV adenosine.

Answer 434

.

Question 435

murmur of atrial septal defect?

Answer 435

-fixed, split S2 in addition to systolic ejection murmur at the left upper sternal border

Question 436

Coarctation of aorta

Answer 436

- associated w/ Turner syndrome | - diminished or absent lower extremity pulses and upper extremity HTN

Question 437

PDA

Answer 437

- continuous machine-like murmur | - strongly associated w/ congenital rubella syndrome

Question 438

Tetralogy of Fallot

Answer 438

-cyanosis, a single second heart sound, and a harsh crescendo-decrescendo murmur caused by right ventricular outflow tract obstruction

Question 439

Truncus arteriosus

Answer 439

-strongly associated w/ DiGeorge syndrome

Question 440

Half of pts w/ Down syndrome have congenital cardiac defects. What are the most common ones?

Answer 440

- failure of endocardial cushion fusion results in AV septal defects - Complete AV septal defects causes heart failure in early infancy (~6 wks) and require surgical repair - Complete AV septal defects > Ventricular septal defect > Atrial septal defect

Question 441

Diastolic and continuous murmurs as well as loud systolic murmurs revealed on cardiac auscultation should always be investigated using TTE. Midsystolic soft murmurs (grade I-II/VI) in an asymptomatic young patient are usually benign and need no further work-up

Answer 441

.

Question 442

Constrictive pericarditis

Answer 442

-important cause of right heart failure and is characterized by progressive peripheral edema, ascites, elevated JVP, pericardial knock (middiastolic sound), and pericardial calcifications on chest x-ray

Question 443

Cardiac amyloidosis

Answer 443

- echo will show increased ventricular wall thickness w/ a normal or nondilated left ventricular cavity - pts w/ amyloidosis may also have heavy proteinuria, periorbital purpura, and hepatomegaly

Question 444

Mitral stenosis

Answer 444

- classically presents during pregnancy | - its most often due to rheumatic fever and occurs much more often in countries w/ limited access to abx

Question 445

Pericardial effusion

Answer 445

- can occur within days or months after cardiac surgery and is referred to as postpericardiotomy syndrome - life-threatening fluid accumulation is characterized by distant heart sounds, hypotension, and distended jugular veins (Beck's triad) and requires drainage

Question 446

Bacterial endocarditis

Answer 446

-fever, new murmur, petechiae, splinter hemorrhages, Osler nodes, Janeway lesions, Roth spots

Question 447

high dose niacin

Answer 447

- used to treat lipid abnormalities, but frequently produces cutaneous flushing and pruritis - prostaglandin-induced peripheral vasodilatation and can be reduced by low-dose aspirin

Question 448

Paroxysmal supraventricular tachycardia (PSVT)

Answer 448

- sudden onset, regular, and narrow-complex tachycardia | - Adenosine and vagal maneuvers can terminate PSVT by transiently slowing SA and AV node conduction

Question 449

In atrial fibrillation (AF) w/ rapid ventricular response (RVR), rate control should be attempted initially w/ beta blockers or calcium channel blockers. Immediate synchronized electrical cardioversion is indicated in hemodynamically unstable pts w/ rapid AF.

Answer 449

.

Question 450

Pts presenting the the ED w/ chest pain and suspected acute coronary syndrome should be administered aspirin as soon as possible! Early antiplatelet therapy w/ aspirin reduces the rate of MI and overall mortality in pts w/ ACS

Answer 450

.

Question 451

PVCs

Answer 451

- common in pts post-MI and can be recognized by their widened QRS (> 120msec), bizarre morphology, and compensatory pause - even though they may indicate a worse prognosis, tx is NOT indicated unless the patient is symptomatic (then give beta blockers)

Question 452

Digoxin can be used to treat atrial arrhythmias like atrial flutter and atrial fibrillation, but it HAS NO ROLE IN THE TREATMENT OF VENTRICULAR ARRHYTHMIAS!!!

Answer 452

.

Question 453

4 anomalies in tetralogy of fallot?

Answer 453

- VSD - RVH - pulmonary stenosis - overriding aorta

Question 454

Tetralogy of Fallot

Answer 454

- presents w/ varying degrees of cyanosis depending on the severity of right ventricular outflow tract obstruction - "Tet" spells result from sudden spasm of the right ventricular outflow tract during exertion - the murmur is typically a harsh crescendo-decrescendo systolic murmur over the left upper sternal border, reflecting turbulence at the stenotic pulmonary artery

Question 455

Infective endocarditis

Answer 455

- can present w/ several nonspecific symptoms and physical exam findings due to immunologic and/or vascular phenomena - early recognition is important to avoid a missed or late diagnosis in such pts - definitive diagnosis is based on Duke Criteria and requires a more comprehensive evaluation

Question 456

Adult Still's disease

Answer 456

- inflammatory disorder characterized by recurrent high fevers (>39C), rash, and arthritis - the rash is often maculopapular and nonpruritic, affecting the trunk and extremities during febrile episodes

Question 457

Variant angina (Prinzmetal's angina)

Answer 457

- vasospastic disorder that typically occurs in young female smokers - chest pain usually occurs in the middle of the night, and episodes are associated w/ transient ST elevations on ECG - treatment is with CCB or nitrates

Question 458

up to 70% of pts w/ mitral stenosis will develop atrial fibrillation because of the significant LEFT atrial dilatation.

Answer 458

.

Question 459

aortic dissection

Answer 459

- causes chest pain that is classically described as sudden, tearing, and radiating to the back - HTN is the most common predisposing factor

Question 460

Marfan's syndrome

Answer 460

- mutation of the FIBRILLIN gene, which results in "weakened" connective tissue - pts are at increased risk for aortic dissection

Question 461

Ehlers-Danlos syndrome

Answer 461

-connective tissue disease involving collagen that can predispose to aortic dissection

Question 462

the fourth heart sound (S4)

Answer 462

-low frequency sound heard at the end of diastole just before S1 that is commonly associated w/ LVH from prolonged HTN

Question 463

Dilated cardiomyopathy

Answer 463

- can be seen following viral myocarditis, particularly after a Coxsackievirus B infection - diagnosis made by Echo, which typically shows dilated ventricles and diffuse hypokinesia resulting in systolic dysfunction (low ejection fraction) - tx is largely supportive, involving mainly the management of CHF symptoms

Question 464

Asymmetric septal hypertrophy

Answer 464

- hypertrophic cardiomyopathy | - young pts; athletes; sudden cardiac death

Question 465

concentric hypertrophy

Answer 465

- follows chronic pressure overload, such as w/ valvular aortic stenosis or untreated HTN - only develops in CHRONIC conditions

Question 466

eccentric hypertrophy

Answer 466

- follows chronic volume overload, as seen in valvular regurgitation - develops slowly over time in response to ventricular volume overload

Question 467

Mitral stenosis

Answer 467

-mid-diastolic murmur and an opening snap, ECG can show left atrial hypertrophy (camel hump, wide P wave in lead II)

Question 468

Exertional heat stroke

Answer 468

- defined as a body temp > 40C (104F) WITH CNS dysfunction or end-organ damage - most commonly induced by strenuous exercise during hot and humid weather - dehydration, hypotension, and tachycardia are common - systemic effects such as seizures, ARDS, DIC, and hepatic/renal failure may also occur - Tx consists of rapid cooling by ice-water immersion and supportive managment

Question 469

Nonexertional (classic) heat stroke

Answer 469

- occurs in absence of strenuous activity and typically affects elderly pts w/ significant underlying comorbidities that limit their ability to escape or cope w/ excessive heat - management involves EVAPORATIVE COOLING, rather than ice-water immersion which is used in exertional heat stroke; this is due to increased mortality with that method in this population

Question 470

Serotonin syndrome vs malignant hyperthermia

Answer 470

- serotonin syndrome: typically seen in pts taking SSRI - malignant hyperthermia: usually triggered by certain anesthetic agents - both conditions cause MUSCULAR RIGIDITY, serotonin syndrome has significant HTN

Question 471

sustained monomorphic ventricular tachycardia (SMVT)

Answer 471

- electrical cardioversion is indicated for SMVT pts who are hemodynamically unstable, pulseless, or severely symptomatic - hemodynamically stable pts can first be given anti-arrhythmics (IV amiodarone) as these may lead to sinus rhythm and avoidance of the need for cardioversion

Question 472

Carotid sinus massage

Answer 472

-useful vagal maneuver to terminate paroxysmal supraventricular tachycardia (PSVT), a regular, narrow-complex tachycardia

Question 473

Digoxin

Answer 473

- used for rate control in SUPRAVENTRICULAR ARRHYTHMIAS (a. flutter, fibrillation, atrial tachycardia), esp in pts w/ hypotension and/or heart failure who are unable to tolerate beta blockers or calcium channel blockers!!!! - can potentially worsen ventricular arrhythmias!

Question 474

Beta blocker overdose

Answer 474

- presents w/ bradycardia, hypotension, wheezing, hypoglycemia, delirium, seizures, and cardiogenic shock - IV fluids and atropine are the first-line treatment options - IV glucagon should be administered in pts w/ profound or refractory hypotension

Question 475

aminophylline

Answer 475

-methylxanthine which acts by blocking phosphodiesterase, thereby increasing levels of cAMP; causes bronchodilation and has positve inotropic/chronotropic effects

Question 476

Digoxin-specific antibody (Fab)

Answer 476

-antidote to digoxin toxicity, which usually presents w/ fatigue, anorexia, nausea, blurred vision, disturbed COLOR PERCEPTION, and cardiac arrhythmias

Question 477

Dobutamine

Answer 477

-inotropic agent that can cause significant vasodilation and worsen hypotension

Question 478

Digitalis toxicity

Answer 478

- causes increased ectopy and increased vagal tone - atrial tachycardia w/ AV block occurs from the combination of these two digitalis effects, and is relatively specific for digitalis toxicity

Question 479

Digitalis can be used to increase vagal tone and is sometimes used to treat atrial fibrillation if beta-blockers or calcium channel blockers have NOT been completely effective

Answer 479

.

Question 480

Multifocal atrial tachycardia is associated with what?

Answer 480

Pulmonary disease

Question 481

Warfarin or target-specific oral anticoagulants (eg rivaroxaban, apixaban, dabigatran) should be used to reduce the risk of systemic thromboembolism in pts w/ atrial fibrillation and moderate to high risk of thromboembolic events (CHA2DS2-VASc score 2 or greater). Pts w/ lone AF (score 0) are at low risk of systemic embolization and anticoagulant therapy is not indicated.

Answer 481

.

Question 482

murmur of aortic regurgitation

Answer 482

- best heard along the left sternal border at the 3rd and 4th interspaces - may be heard in some pts only by applying firm pressure w/ the diaphragm of the stethoscope while the patient is sitting up, leaning forward, and holding breath in full expiration - congenital bicuspid aortic valve is the most common cause of AR in young adults in developed countries - Rheumatic heart disease is the most common cause in developing countries

Question 483

Innocent cardiac murmurs

Answer 483

- result from normal blood flow from a structurally normal heart - the intensity is typically grade 1 or 2 and DECREASES with maneuvers that decrease venous blood return, such as standing. - benign murmurs are also early or mid-systolic in timing - management consists of observation and reassurance

Question 484

which meds to hold prior to cardiac stress test?

Answer 484

- Beta blockers, calcium channel blockers, and nitrates are anti-anginal agents and should be withheld for at least 48 hrs prior to cardiac stress testing - however, these meds should be continued in pts w/ known CAD undergoing stress testing to assess the efficacy of antianginal therapy

Question 485

Mobitz type 1 second degree AV block

Answer 485

- progressive prolongation of PR interval leading to a non-conduction P wave and a dropped QRS complex - the PR interval prolongation is best appreciated by measuring the PR intervals just before and after the dropped QRS complex - constant PP interval, decreasing RR interval

Question 486

PACs

Answer 486

- indicate depolarization of the atria originating in a focus outside the SA node - they are seen on ECG as a P wave w/ abnormal morphology, often occurring earlier in the cardiac cycle than a normal P wave

Question 487

Impaired SA node automaticity

Answer 487

- leads to sick sinus syndrome, which is often due to degeneration and/or fibrosis of the SA node and surrounding atrial myocardium - pts may present w/ fatigue, lightheadedness, palpitations, presyncope, or syncope - ECG often shows bradycardia, sinus pauses/arrest, SA exit block, or alternating bradycardia and atrial tachyarrhythmias (tachy-brady syndrome)

Question 488

Wolff-Parkinson-White syndrome

Answer 488

- ventricular preexcitation that is due to an accessory conduction pathway that directly connects the atria and ventricle, bypassing the AV node - the ECG shows a characteristic pattern of short PR interval (

Question 489

Gastroesophageal reflux in infants

Answer 489

- extremely common due to their shorter esophagus, incomplete closure of the lower esophageal sphincter, and greater time spent in the supine position - parents should be reassured about adequate weight gain and advised to hold the infant upright after feeds

Question 490

Indicators of a severe asthma attack

Answer 490

-include normal to increased PCO2 values, speech difficulties, diaphoresis, altered sensorium, cyanosis, and "silent" lungs

Question 491

Immobilization of an individual w/ high bone turnover results in increased osteoclastic activation that can lead to hypercalcemia. Bisphosphonate therapy and hydration in immobilized pts is helpful in reducing hypercalcemia and preventing osteopenia

Answer 491

.

Question 492

approx. 40% of circulating serum calcium is bound to proteins, mostly albumin. Changes in the albumin level will affect the total serum calcium without affecting the ionized fraction.

Answer 492

.

Question 493

causes of hypercalcemia in malignancy

Answer 493

-local osteolytic metastasis, secretion of parathyroid hormone-related protein (PTHrP), and increased formation of 1,25-dihydroxyvitamin D

Question 494

Malaria

Answer 494

- should be suspected in any ill pts, esp. those w/ a hx of febrile paroxysms, who have traveled to an endemic-tropical region - thick and thin blood smears should be ordered for parasite detection and quantification - nonimmune children are at highest risk of death, but the sickle cell trait confers some protection from severe complications - Plasmodium falciparum, P. vivax, P. ovale, or P. malariae transmitted by bite of infected Anopheles mosquito - antimalarial drugs: atovaquone-proguanil, doxycycline, mefloquine, chloroquine, hydroxychloroquine

Question 495

Monosymptomatic (isolated) enuresis

Answer 495

- urinary incontinence in children age >5 - urinalysis, urologic imaging for children w/ significant daytime sx and hx of recurrent UTI - avoid sugary/caffeinated beverages, void regularly during the day and immediately before bed, drink ample fluids in the morning and early afternoon; minimize fluid intake before bed, reward system - ENURESIS ALARM: 1st line intervention when behavior modifications fail; best long-term outcome - meds: DESMOPRESSION (1st line), TCAs (2nd line)

Question 496

anterior MI on ECG

Answer 496

- blocked vessel is LAD | - some or all of leads V1-V6 involved

Question 497

inferior MI on ECG

Answer 497

- RCA or L circumflex artery | - ST elevation in leads II, III, and aVF

Question 498

posterior MI on ECG

Answer 498

- L circumflex or RCA - ST depression in leads V1-V3 - ST elevation in leads I and aVL (LCX) - ST depression in leads I and aVL (RCA)

Question 499

Lateral MI on ECG

Answer 499

- L circumflex, or diagonal artery - ST elevation in leads I, aVL, V5 and V6 - ST depression in leads II, III, and aVF

Question 500

Right ventricle MI (occurs in 1/2 of inferior MI) on ECG

Answer 500

- RCA | - ST elevation in leads V4-V6R

Question 501

The right coronary artery supplies blood to the AV node through the AV nodal artery in 90% of pts; and RCA occlusion can cause AV block. Inferior MI is most commonly associated w/ sinus bradycardai due to increased vagal tone in the first 24 hrs after infarction and decreased RCA blood supply to the SA node

Answer 501

.

Question 502

Right coronary artery occulsion

Answer 502

- can cause acute inferior and posterior wall MIs - inferior wall MI presents w/ ST segment elevations in the inferior leads (II, III, and aVF) - ST segment depression in leads V1 and V2 in this setting usually suggests a posterior wall MI - Inferior MI is also associated w/ hypotension, bradycardia, and AV block

Question 503

Acute pericarditis on ECG

Answer 503

-diffuse PR segment depression and diffuse ST segment elevation across multiple limb and precordial leads

Question 504

Left anterior descending coronary artery occlusion

Answer 504

- LAD usually supplies the anterior walls of the left ventricle as well as the anterior 2/3rds of the septum - occlusion of this vessel can cause ST segment elevation in all precordial leads, but most commonly in V1-V4 - second degree AV block can be seen

Question 505

Left circumflex coronary artery

Answer 505

- supplies the posterolateral wall of the left ventricle | - occlusion can cause ST segment elevation in leads I, II, III, and aVL

Question 506

Occlusion of the left main coronary artery

Answer 506

- usually a catastrophic event and presents as sudden cardiac death in the majority of pts - occlusion of both LCX and LAD causes ST segment elevations in anterior and lateral leads (I aVL, V1-V6)

Question 507

In pts w/ sickle cell disease, acute severe anemia w/ low or absent reticulocytes

Answer 507

- APLASTIC CRISIS - this is an acute drop in Hgb and is known complication of sickle cell disease - alternative things that can cause an acute drop in Hgb: hyperhemolytic crisis, splenic sequestration, or an aplastic crisis - aplastic crisis is a transient arrest of erythropoiesis that results in a severe drop in Hgb and virtual absence of reticulocytes on peripheral smear (reticulocytes

Question 508

hyperhemolytic crisis

Answer 508

- rare complication of sickle cell disease that is characterized by a sudden, severe anemia accompanied by an APPROPRIATE RETICULOCYTOSIS (in contrast to aplastic crisis) - etiology unknown

Question 509

Splenic sequestration

Answer 509

- occurs in sickle cell pts who have not yet developed auto-splenectomy - caused by vasoocclusion and pooling of red cells within the spleen, which may lead to severe hypotensive shock - characterized by a dramatic drop in Hgb concentration that is accompanied by persistent reticulocytosis - physical exam shows a rapidly enlarging spleen - mortality rate of 10-15% and 50% chance of recurrence, so splenectomy is usually recommended after the first episode

Question 510

Acute chest syndrome

Answer 510

- characterized by the presence of fever, chest pain, and an infiltrate on chest x-ray - multifactorial and related to pulmonary infarction and infection

Question 511

vasoocclusive crisis

Answer 511

- acute onset of pain and caused by vasoocclusion secondary to the sickling of RBCs - these crises may be precipitated by changes in weather, dehydration, or infection

Question 512

Oliguria, azotemia and an elevated BUN/creatinine ratio of >20:1 in the post-op state

Answer 512

- pre-renal failure from hypovolemia most likely, though urinary catheter obstruction should first be ruled out - the next step in diagnosis/management of acute renal failure manifesting as oliguria or anuria is an IV fluid challenge

Question 513

pre-renal vs intrinsic renal disease

Answer 513

-elevated BUN/Cr ratio > 10:1 and FENa 1 is intrinsic renal

Question 514

finding of atypical squamous cells of undetermined significance on cytology

Answer 514

- women age 21-24 yrs: repeat cytology in 1 year - women age >25 yrs: HPV DNA test; those who test positive for HPV require colposcopy; pts w/ a negative HPV test can be followed w/ repeat Pap smear and HPV test in 3 yrs

Question 515

routine cervical cancer screening guidelines

Answer 515

- cytology every 3 yrs or a combo of cytology and HPV DNA test every 5 yrs in women age >30 yrs - for women age 21-29 yrs, cytology every 3 yrs is recommended

Question 516

Central retinal artery occlusion syndrome

Answer 516

- ophthalmologic emergency! - treated w/ an ocular massage and high-flow oxygen! - painless loss of monocular vision - risk factors: carotid artery disease, endocarditis, cardiac valvular disease, long bone fx, hypercoagulable states, vasculitis, atrial myxoma - amaurosis fugax

Question 517

management of acute angle closure glaucoma

Answer 517

- topical pilocarpine and beta-blockers | - sudden, painful loss of vision w/ red eye

Question 518

oropharyngeal dysphagia

Answer 518

-difficulty w/ initiating swallowing associated w/ coughing, choking, or nasal regurgitation

Question 519

esophageal dysphagia

Answer 519

- can initiate swallowing but have difficulty passing the food down the esophagus - dysphagia which is initially w/ solids but eventually liquids favors a mechanical obstruction - progressive dysphagia suggests esophageal stricture or cancer - nonprogressive dysphagia favors esophageal rings - upper GI endoscopy is initially recommended except in pts w/ hx of prior radiation, caustic injury, complex stricture, or surgery for esophageal/laryngeal cancer; these pts have increased risk of perforation w/ endoscopy and can benefit from having a barium swallow first; pts w/ negative endoscopy should then have barium swallow for further evaluation - pts w/ dysphagia to liquids and solids at onset favor a motility disorder; intermittent dysphagia suggest a primary esophageal motility disorder; progressive dysphagia indicates secondary causes such as achalasia or systemic sclerosis (scleroderma); barium swallow is recommended initially for these pts as its more effective than endoscopy in evaluating motlity disorders; pts who have a barium swallow suggesting a motility disorder then undergo esophageal motility studies (manometry) to confirm the diagnosis

Question 520

24 hr pH monitoring

Answer 520

-might be helpful to confirm diagnosis of gatroesophageal reflux

Question 521

Bee stings are a common cause of anaphylaxis. Anaphylaxis requires emergency administration of IM epinephrine to prevent and treat respiratory distress and circulatory collapse.

Answer 521

.

Question 522

what is the treatment of all nondisplaces scaphoid fractures (fractures w/

Answer 522

- wrist immobilization for 6-10 wks - if x-rays are negative but suspicion is high, immobilize wrist and re-image in 7-10 days or proceed immediately w/ CT scan

Question 523

Orthotopic liver transplantation remains the only effective mode of treatment of fulminant hepatic failure and should be considered in any patient presenting w/ this condition, regardless of etiology. Contraindications include: irreversible cardiopulmonary disease, incurable or recent (

Answer 523

.

Question 524

Diagnostic peritoneal lavage

Answer 524

-done on hemodynamically UNSTABLE pts w/ BLUNT abdominal trauma and INCONCLUSIVE FAST exam

Question 525

any penetrating wound below the 4th intercostal space (ie level of the nipples) is considered to involve the abdomen and requires an exploratory laparotomy in unstable pts

Answer 525

.

Question 526

CURB-65

Answer 526

- Pneumonia hospitalization criteria, 2-3 = consider inpatient tx; > 4 = admission - Confusion - Uremia (BUN > 19) - Respiratory rate ( > 30 breaths/min) - Blood pressure (SBP 65 yrs

Question 527

common causes of pneumonia by age

Answer 527

- neonates: GBS, E. coli, Listeria - children: Viruses, S. pneumo, Mycoplasma, Chlamydia pneumoniae, S. aureus - adults (18-40): Mycoplasma, S. pneumo, Viruses, C. pneumoniae - adults (40-65): S. pneumo, H. influenza, Mycoplasma, Viruses, Anaerobes - elderly: S. pneumo, H. influenza, Viruses, S. aureus, gram - rods, anaerobes

Question 528

atypical pneumonia

Answer 528

-MCL (mycoplasma, chlamydophila, legionella)

Question 529

nosocomial pneumonia

Answer 529

-GNRs, Staph, anaerobes, Pseudomonas (intubated pts)

Question 530

Immunocompromised pneumonia

Answer 530

-Staph, gram + rods, fungi, viruses, Pneumocystis jirovecii (w/ HIV), mycobacteria

Question 531

Alcoholics/IV drug users pneumonia

Answer 531

-S. pneumo, Klebsiella, Staph

Question 532

Cystic fibrosis pneumonia

Answer 532

-staph, Pseudomonas, Burkholderia, mycobacteria

Question 533

COPD pneumonia

Answer 533

-H. influenza, Moraxella catarrhalis, S. pneumo

Question 534

Postviral pneumonia

Answer 534

-Staph, S. pneumo, H. influenza

Question 535

recurrent pneumonia

Answer 535

-obstruction, bronchogenic carcinoma, lymphoma, Wegener granulomatosis, immunodeficiency, unusual organisms (Nocardia, Coxiella burnetii, Aspergillus, Pseudomonas)

Question 536

Tx for suspected community acquired pneumonia

Answer 536

macrolide or doxycycline

Question 537

Tx for pneumonia in > 65 or w/ comorbidities

Answer 537

Fluoroquinolone or B-lactam + macrolide

Question 538

tx of pneumonia requiring ICU care

Answer 538

antipneumococcal B-lactam + either azithromycin or fluoroquinolone

Question 539

Tx of hospital acquired pneumonia

Answer 539

- extended spectrum cephalosporin or carbapenem w/ antipseudomonal activity - add an aminoglycoside or a fluoroquinolone for coverage of resistant organisms (Pseudomonas) until lab sensitivities are back

Question 540

common side effects of TB meds

Answer 540

- Rifampin turns body fluids red/orange - Ethambutol can cause optic neuritis - INH causes peripheral neuropathy and hepatitis

Question 541

how to diagnose active and latent TB?

Answer 541

- active: sputum culture or gram stain for acid-fast bacilli; chest x-ray - latent: PPD and chest x-ray

Question 542

Tx of TB

Answer 542

active disease: directly observe tx w/ 4 drug regimen (INH, pyrazinamide, rifampin, ethambutol) x 2 months followed by INH and rifampin for 4 months; must give vitamin B6 w/ INH! latent disease: + PPD w/o symptoms needs INH x 9 months or INH x 6 months or rifampin x 4 months

Question 543

PPD readings as positive

Answer 543

>5 mm: HIV or risk factors, close TB contacts, CXR evidence of TB >10 mm: indigent/homeless, residents of developing nations, IV drug use, chronic illness, prisoners, healthcare workers > 15 mm: everyone else, including those w/ no known risk factors -note that a negative test w/ negative controls implies anergy from immunosuppression, old age, or malnutritions and does NOT rule out TB

Question 544

Lemierre syndrome

Answer 544

-thrombophlebitis of the jugular vein due to Fusobacterium, an oral anaerobe

Question 545

Modified Centor criteria

Answer 545

- used to determine tx plan for acute pharyngitis - Fever 1 point - tonsillar exudate 1 point - tender anterior cervical lymphadenopathy 1 point - lack of cough 1 point - 3-14 yrs of age 1 point - 15-45 yrs of age 0 point - > 45 yrs of age -1 point - if 4-5 points, treat empirically; if 2-3 points, perform rapid antigen test. if + test, treat w/ abx. if - test, perform throat culture; if 0-1 point, no testing or abx required, symptomatic tx only

Question 546

tx of acute bacterial sinusitis

Answer 546

-amoxicillin/clavulanate for 10 days or clarithromycin, azithromycin, TMP-SMP, a fluoroquinolone, or a second-generation cephalosporin for 10 days

Question 547

meningitis in newborn

Answer 547

- GBS - E. coli/GNRs - Listeria

Question 548

meningitis in children

Answer 548

- S. pneumo - N. meningitidis - H. influenza serotype b - Enteroviruses

Question 549

meningitis in adults

Answer 549

- N. meningitidis (#1 in teens) - S. pneumo - Enteroviruses - HSV

Question 550

meningitis in elderly

Answer 550

- S. pneumo - GNRs - Listeria - N. meningitidis

Question 551

meningococcal meningitis

Answer 551

- petechial or purpuric rash - waterhouse-friderichsen syndrome (adrenal insufficiency due to bleeding into the adrenal gland) is characterized by profound hypotension and has high mortality

Question 552

how to differentiate Guillain-Barre from MS on LP?

Answer 552

GB has high protein levels in CSF; MS has high gamma globulin in CSF

Question 553

Tx of bacterial meningitis

Answer 553

Give abx as soon as possible! - close contacts w/ meningococcal meningitis should receive Rifampin, Ciprofloxacin, or ceftriaxone - Dexamethasone decreases complications in S. pneumo meningitis only! - if immunocompromised, elderly, or neonate, add ampicillin for Listeria - 60 yrs/alcoholism/chronic illness: Ampicillin + vancomycin + cefotaxime or ceftriaxone

Question 554

The presence of RBCs in CSF without a hx of trauma is highly suggestive of what?

Answer 554

- HSV encephalitis | - subarachnoid hemorrhage

Question 555

most common causes of encephalitis

Answer 555

-HSV and arboviruses

Question 556

Giemsa stain

Answer 556

trypanosomes

Question 557

Tx for common encephalitis conditions

Answer 557

- HSV encephalitis: IV acyclovir - CMV encephalitis: IV ganciclovir +/- foscarnet - Doxycycline for Ricketsia such as Rocky Mountain spotted fever or ehrlichiosis - Lyme encephalitis: Ceftriaxone

Question 558

classic triad in brain abscess

Answer 558

headache, fever, and a focal neurologic deficit

Question 559

Treatment of brain abscess

Answer 559

-broad spectrum IV antibiotics and surgical drainage; lesions

Question 560

AIDS defining illnesses

Answer 560

- Esophageal candidiasis - CMV retinitis - Kaposi sarcoma (HHV-8) - CNS lymphoma, toxoplasmosis, PML - P. jirovecii pneumonia or recurrent bacterial pneumonia - HIV encephalopathy - Disseminated mycobacterial or fungal infection - invasive cervical cancer

Question 561

If a pregnant HIV + patient is not on ART at the time of delivery, she should be treated w/ Zidovudine (AZT) intrapartum. Infants should receive AZT for 6 wks after birth

Answer 561

.

Question 562

initial tx regimen for HIV?

Answer 562

-combo of 2 nucleoside/nucleotide reverse transcriptase inhibitors (RTIs), plus either one non-nucleoside RTI or one protease inhibitor or one integrase inhibitor

Question 563

common side effects of HIV meds

Answer 563

- Protease inhibitors: hyperglycemia, hyperlipidemia, lipodystrophy - Nucleoside RTIs: bone marrow suppression, neuropathy - Indinavir: crystal induced nephropathy, nephrolithiasis - Didanosine: pancreatitis - Abacavir: hypersensitivity rxn - Nevirapine: liver failure - Efavirenz: vivid dreams, hallucinations

Question 564

what are the only live vaccines that should be given to HIV pts (if CD4 > 200)?

Answer 564

MMR and varicella

Question 565

Prophylaxis for HIV related opportunistic infections

Answer 565

P. jirovecii: CD4 5mm or high risk; INH x 9mo (+pyridoxine) or rifampin x 4 mo Candida: fluconazole or fluconazole or nystatin mouth wash HSV: daily suppressive acyclovir, famciclovir, or valacyclovir S. pneumo: Pneumovax every 5 yrs if CD4 > 200 Influenza: annual vaccine

Question 566

Aspergillus appearance

Answer 566

- 45 degree angle branching septate hyphae (think of the capital letter "A" and how it's angle is 45 degrees) - rare fruiting bodies

Question 567

cryptococcus appearance

Answer 567

- yeasts w/ wide capsular halo | - narrow-based buds

Question 568

Mucor appearance

Answer 568

-irregular broad nonseptate hyphae, wide-angle branching

Question 569

the CSF antigen test for cryptococcal meningitis is highly sensitive and specific. Can also use india ink stain

Answer 569

.

Question 570

how to differentiate thrush from hairy leukoplakia?

Answer 570

thrush can be easily rubbed off, hairy leukoplakia cannot

Question 571

tx of cryptococcal meningitis

Answer 571

-IV amphotericin B + flucytosine x 2 wks; then fluconazole x 8 wks

Question 572

diagnosis of histoplasmosis

Answer 572

CXR: diffuse nodular densities, focal infiltrate, cavity, or hilar lymphadenopathy Urine and serum polysaccharide antigen test is most sensitive.

Question 573

Tx of histoplasmosis

Answer 573

- mild: supportive or itraconazole - moderate: itraconazole for > 1 year - severe: liposomal amphotericin B followed by itraconazole for 1 yr or greater

Question 574

appearance of histoplasmosis

Answer 574

-histiocyte macrophage containing numerous yeast cells

Question 575

Nocardia

Answer 575

- partially acid-fast, gram +, branching rod found in soil that is a common cause of lung and CNS infection in immunocompromised - TMP-SMX is treatment

Question 576

Hypercalcemia of malignancy

Answer 576

- most commonly (80%) due to parathyroid hormone-related peptide (PTHrP) production - other mechanisms include excess vitamin D production, bone metastasis w/ local cytokine release to induce bone resorption, and ectopic PTH production - breast cancer most commonly causes hyper calcemia by producing PTHrP, either systemically or locally by bone metastases

Question 577

cytokines produce in osteoclastic bone resorption in malignancies (multiple myeloma, lymphomas, leukemia)?

Answer 577

- IL-6 - IL-3 - RANK-L - TNF-a - macrophage inflammatory factor 1-a

Question 578

Ectopic PTH production is an extremely rare cause of hypercalcemia of malignancy. PTH-independent hypercalcemia usually has serum PTH levels 40 pg/mL. PTH levels of 20-40 pg/mL are considered indeterminant. When both calcium and PTH levels are elevated in malignancy pts, its imperative to rule out coexistent primary hyperparathyroidism before diagnosing ectopic PTH production by the tumor.

Answer 578

.

Question 579

Peripheral artery aneurysm

Answer 579

- manifests as a pulsatile mass that can compress adjacent structures (nerves, veins) and can result in thrombosis and ischemia - popliteal and femoral artery aneurysms are the most common peripheral artery aneurysms - they are frequently associated w/ AAA

Question 580

Inguinal hernias are located above the inguinal ligament; an indirect hernia may descend into the scrotum

Answer 580

.

Question 581

when choosing between meds for depression, consider tx guidelines as well as the safety and side effect profiles. Also, consider a med that may be effective for more than one condition. Buproprion is an example of a med w/ 2 uses, as it is an antidepressant and a smoking cessation aid

Answer 581

.

Question 582

uses for amitriptyline other than depression?

Answer 582

diabetic neuropathy and prevention of migraine headaches

Question 583

mirtazapine

Answer 583

effective antidepressant; however, weight gain is fairly common

Question 584

Phenelzine

Answer 584

MAOI

Question 585

Cushing's syndrome

Answer 585

- if due to ectopic ACTH production, it causes rapid onset of HTN, metabolic alkalosis, hyperglycemia, hypokalemia, and proximal muscle weakness - in contrast to Cushing's DISEASE (ACTH-producing pituitary adenoma), administration of high-dose dexamethasone does NOT suppress plasma cortisol levels in most pts w/ ectopic ACTH syndrome - ACTH independent: usually due to exogenous steroids, adrenal adenoma, or primary pigmented nodular adrenocortical hyperplasia; get an adrenal CT to exlude adrenal adenoma - ACTH dependent: most commonly due to Cushing's disease (ACTH-producing pituitary adenoma), ectopic ACTH production, or ectopic CRD production; due a high-dose dexamethasone suppression test; failure to suppress serum cortisol levels by 50% makes ectopic ACTH most likely

Question 586

first step in management of a suspected urethral injury

Answer 586

-retrograde urethrogram (helps determine urethral injury and location for repair)

Question 587

Sporotrichosis

Answer 587

- gardener's disease - the initial lesion, a reddish nodule that later ulcerates, appears at the site of the thorn prick or other skin injury - from the site of inoculation, the fungus spreads along the lymphatics forming subcutaenous nodules and ulcers

Question 588

Metoclopramide

Answer 588

- prokinetic agent used to treat nausea, vomiting, and gastroparesis - pts taking this med should be monitored closely for the development of drug-induced extrapyramidal symptoms (dystonic rxn most commonly; tx involves stopping the drug and giving benztropine or diphenhydramine)

Question 589

4 questions to ask when evaluating case of arthritis?

Answer 589

1. Is it an inflammatory process? 2. Is it monarticular or polyarticular? 3. Is it symmetric or asymmetric? 4. What is the duration of symptoms?

Question 590

Viral arthritis

Answer 590

- can preset w/ symmetric small joint inflammatory arthritis - distinguished from other causes of symmetric inflammatory arthritis by the fact that it tends to resolve within two months - positive inflammatory markers such as ANA and rheumatoid factor may occur - tx involves NSAIDs for resolution of symptoms - antiviral therapy is unnecessary as the symptoms are self-limited - causative agents include: parvovirus, hepatitis, HIV, mumps, and rubella among many others

Question 591

seronegative spondyloarthropathies

Answer 591

- include ankylosing spondylitis, reactive arthritis, and psoriatic arthritis - asymmetric arthritis and inflammatory back pain w/ a negative rheumatoid factor

Question 592

Polymyalgia rheumatica

Answer 592

- occurs most commonly in pts over 50 - inflammatory condition which presents w/ sore and stiff muscles, particularly in the neck and shoulders - ESR typically > 40, while the ANA is normal

Question 593

missed abortion

Answer 593

- variable presentation from no symptoms to light vaginal bleeding - pregnancy symptoms may decrease - CLOSED cervix - Nonviable fetus on US

Question 594

Inevitable abortion

Answer 594

- vaginal bleeding, uterine cramps - possible intrauterine fetus w/ heartbeat - OPEN cervix; fetus w/ possible heartbeat on US

Question 595

Incomplete abortion

Answer 595

- vaginal bleeding w/ passage of large clots or tissue - uterine cramps - products of conception often visualized in dilated cervical os - OPEN cervix; products of conception often in cervix

Question 596

Threatened abortion

Answer 596

- variable amount of vaginal bleeding - pregnancy can proceed to viable birth - CLOSED cervix; viable pregnancy on US

Question 597

Septic abortion

Answer 597

- fever, malaise, signs of sepsis - foul smelling vaginal discharge, cervical motion and uterine tenderness - rarely occurs after spontaneous abortion - usually w/ induced abortions, can be life-threatening - USUALLY OPEN cervix; usually retained products of conception on US

Question 598

missed abortion

Answer 598

- form of spontaneous abortion (defined as intrauterine fetal death before 20 wks gestational age) w/ complete retained products of conception and a closed cervix - pts often develop loss of pregnancy symptoms and scant to light vaginal discharge - pelvic US is necessary for diagnosis

Question 599

Inevitable, missed, and incomplete abortions can be managed surgically, medically, or expectantly. Although all 3 methods can be effective, surgery achieves more complete evacuation than medical or expectant management. In the case of medical and expectant management, US is generally performed to confirm that there are no retained POC.

Answer 599

.

Question 600

Complete androgen insensitivity syndrome

Answer 600

- x linked mutation of androgen receptor - breast development present - absent uterus and upper 1/3 of vagina; cryptorchid testes - minimal to absent pubic and axillary hair - 46 XY

Question 601

Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome)

Answer 601

- Hypoplastic or absent mullerian ductal system - breast development present - absent or rudimentary uterus and upper 1/3 of vagina; normal ovaries - normal pubic and axillary hair - 46 XX

Question 602

Transverse vaginal septum

Answer 602

- malformation of urogenital sinus and Mullerian ducts - breast development present - normal uterus, abnormal vagina; normal ovaries - normal pubic and axillary hair - 46 XX

Question 603

Turner syndrome

Answer 603

- complete/partial absence of 1 X chromosome - variable breast development depending on ovarian function - normal uterus and vagina; streak ovaries - normal axillary and pubic hair - 45 X

Question 604

Primary amenorrhea

Answer 604

-absence of menses by age 15 in someone who has normal growth and secondary sexual characteristics

Question 605

Androgen insensitivity syndrome

Answer 605

- caused by mutated androgen receptor that results in end-organ resistance to androgens - 46 XY pts have testicular secretion of anti-Mullerian hormone, resulting in primary amenorrhea - in addition, testosterone secreted from the testes is converted to estrogen, resulting in breast development

Question 606

46 XY individuals w/ 5a-reductase deficiency

Answer 606

- cannot convert testosterone to DHT | - ambiguous genitalia at birth (undervirilization) and a male internal urogenital tract (due to AMH)

Question 607

Epiglottitis

Answer 607

- presents w/ abrupt onset of fever, sore throat, dysphagia, and drooling - airway obstruction is the most concerning potential complication, and often requires nasotracheal intubation - in unimmunized children, H. influenza type b is a likely cause

Question 608

Peritonsillar abscess

Answer 608

- fever, sore throat, muffled voice, and occasionally drooling - unilateral tonsillar swelling w/ uvular deviation

Question 609

vascular rings

Answer 609

-rare congenital anomaly where aortic arch remnants encircle and compress the trachea or esophagus

Question 610

croup

Answer 610

- most commonly caused by parainfluenza virus type 1 - fever, TRIDOR, and barking cough - drooling is UNCOMMON - Corticosteroids or nebulized epinephrine may be used in tx

Question 611

foreing body aspiration

Answer 611

- common cause of respiratory distress in children - pts w/ a laryngeal foreign body present w/ wheezing and in severe cases, cyanosis - diagnosis typically confirmed radiographically - rigid bronchoscopy is used to remove foreign body

Question 612

Duodenal ulcer disease

Answer 612

- typically presents w/ epigastric pain that improves w/ eating (alkali solution is injected into duodenum w/ food ingestion; this is in contrast to GASTRIC ulcers, which get worse w/ food ingestion due to acid increase in stomach) - over 90% of pts w/ duodenal ulcer disease are infected w/ H. pylori - tx is acid suppression w/ PPI and amoxicillin plus clarithromycin

Question 613

Tourette syndrome

Answer 613

- multiple motor and one or more vocal tics that present before the age of 18; grimacing, eye blinking, nose twitching, head jerking, and shoulder shrugging, barking, grunting, squeaking, coughing, throat clearing, coprolalia - sx exacerbated by stress and tend to subside during sleep - comorbid conditions: ADHD, OCD

Question 614

Apgar scores

Answer 614

- helpful in assessing the STATUS of a neonate and RESPONSE to neonatal resuscitation - routinely measured at 1 and 5 minutes; most infants score 7-9/10 - scores

Question 615

APGAR score

Answer 615

- Appearance/color: completely blue/pale 0 points, body pink and extremities blue 1 point, completely pink 2 points - Pulse: absent 0 points, 100/min 2 points - Grimace/reaction: absent 0 points, grimace/whimper 1 point, cough/sneeze/cry 2 points - Activity/muscle tone: limp 0 points, some flexion 1 point, active/spontaneous 2 points - Respiratory effort: absent 0 points, slow/weak cry 1 point, regular good cry 2 points

Question 616

Sleep apnea syndrome

Answer 616

-typical presentation is a moderately obese middle-aged man complaining of daytime somnolence, morning headaches, increased fatigability, and who is noted to snore loudly. Try weight reduction, avoidance of sedatives and alcohol, and avoidance of supine posture during sleep as a first step

Question 617

Cystic fibrosis

Answer 617

- common AUTOSOMAL RECESSIVE disease characterized by recurrent sinopulmonary infections - bilateral nasal polyps exacerbate nasal obstruction and chronic rhinosinusitis - Quantitative pilocarpine iontophoresis is the gold standard for diagnosis!

Question 618

ALL

Answer 618

- most common cause of childhood cancer - numerous infections and weight loss - Hepatosplenomegaly, lymphadenopathy, and petechiae are often seen

Question 619

Primary ciliary dyskinesia (immotile-cilia syndrome)

Answer 619

- autosomal recessive disorder of mucociliary clearance | - recurrent sinopulmonary infections, nasal polyposis, and digital clubbing

Question 620

Tachycardia-mediated cardiomyopathy

Answer 620

- can develop in pts who have persistent or recurrent tachyarrhythmia w/ prolonged periods of rapid ventricular rate - initial tx is aimed at restoration of sinus rhythm or aggressive control of ventricular rate and can lead to significant improvement in left ventricular function

Question 621

The most common renal vascular lesions seen in HTN are arteriosclerotic lesions of afferent and efferent renal arterioles and glomerular capillary tufts. DM nephropathy is characterized by increased extracellular matrix, basement membrane thickening, mesangial expansion, and fibrosis

Answer 621

.

Question 622

Diabetic nephropathy

Answer 622

- leading cause of end stage renal disease in US - increased extracellular matrix, BM thickening, mesangial expansion, and fibrosis - within the first year: glomerular HYPERFUSION and renal HYPERTROPHY w/ INCREASED GFR - first five years: glomerular BM thickening, glomerular hypertrophy, and mesangial volume expansion w/ GFR returning to normal - within 5-10 yrs: microalbuminuria, which later progresses to overt nephropathy

Question 623

Analgesic abuse nephropathy is primarily a tubulointerstitial disease characterized by focal glomerulosclerosis

Answer 623

.

Question 624

what is the major cause of delayed morbidity and mortality in subarachnoid hemorrhage?

Answer 624

Vasospasm | -vasospasm can best be prevented w/ initiation of NIMODIPINE

Question 625

REBLEEDING is the major cause of death within the FIRST 24 HRS of subarrachnoid hemorrhage, especially within the first 6 hrs of untreated SAH. VASOSPASM can occur in up to 30% of SAH pts from day 3-10 after presentation and is the major cause of DELAYED MORBIDITIY AND DEATH.

Answer 625

.

Question 626

Whipple disease

Answer 626

- multisystem disorder w/ a varied presentation caused by infection w/ the gram-positive bacillus Tropheryma whippelii - chronic malabsorptive diarrhea, weight loss, migratory non-deforming arthritis, lymphadenopathy and a low-grade fever are the most common presenting symptoms - diagnosis made by small intestinal biopsy and PCR; shows PAS-positive macrophages in the lamina propria containing non-acid fast gram positive bacilli

Question 627

Reactive arthritis

Answer 627

- occurs following an infection - HLA-B27 associated reactive arthropathy characterized by conjunctivitis, urethritis, and arthritis - typically follows infections by Chlamydia, Shigella, Salmonella, Yersinia, Campylobacter, and C. diff

Question 628

Non-caseating granulomas

Answer 628

Sarcoidosis

Question 629

UC shows acute and chronic inflammation of the mucosa leading to CRYPT ABSCESS FORMATION. Crohn disease shows full-thickness inflammation w/ granuloma and lymphoid aggregate formation and skin lesions.

Answer 629

.

Question 630

Celiac disease (celiac sprue, gluten-sensitive enteropathy)

Answer 630

- autoimmune disease causing malabsorptive diarrhea | - anti-endomysial and anti-transglutaminase antibodies and histopath shows effacement of small intestinal villi

Question 631

Intestinal lymphoma

Answer 631

- abdominal pain, weight loss, N/V, distention, and occult blood in stool - diffuse infiltrate by atypical lymphocytes

Question 632

The first step in the care of pts w/ acute suicidality is to ensure their safety by admitting them to a psych unit (against their will if necessary). A major depressive episode can occur in response to loss of a loved one, but it differs from normal grief and must be treated appropriately. The most significant suicide risk factors are a PREVIOUS ATTEMPT and a CLEAR PLAN. Having a clear plan is what differentiates the need for immediate hospitalization vs outpatient management.

Answer 632

.

Question 633

Consider CMV infection in a patient w/ mononucleosis-like symptoms, atypical lymphocytes on the blood smear, and a negative monospot test. Unlike EBV-associated mononucleosis, sore throat and lymphadenopathy are UNCOMMON in CMV infection

Answer 633

.

Question 634

CLL

Answer 634

-affects pts over 60; mature-appearing small lymphocytes and "smudge" cells are seen

Question 635

Inflammatory bowel disease

Answer 635

- may occur in association w/ an inflammatory arthritis - ankylosing spondylitis and IBD are both associated w/ HLA-B27 and may occur in association w/ one another - Both conditions may also be associated w/ a positive p-ANCA despite the absence of vasculitis in both conditions.

Question 636

Reactive arthritis

Answer 636

- may follow infectious diarrhea caused by Shigella, Salmonella, Yersinia, Campylobacter, or C. diff - urethritis, conjunctivitis/uveitis, arthritis, malaise and skin findings (keratoderma blennorrhagica and balanitis circinata)

Question 637

Characteristic cutaneous finding of Celiac disease

Answer 637

Dermatitis herpetiformis

Question 638

common cutaneous finding in UC

Answer 638

erythema nodosum, pyoderma gangrenosum

Question 639

Infection by the protozoan Giardia lamblia typically causes a frothy, foul-smelling steatorrhea due to malabsorption caused by the infecting organism. Bloody diarrhea is uncommon.

Answer 639

.

Question 640

Blood in the chest, if it is not evacuated by surgery, can get infected. The majority of pts will present w/ a low-grade fever, dyspnea, and chest pain. Surgery is required to remove the clotted blood and fibrinous peel.

Answer 640

.

Question 641

Rubella (german measles)

Answer 641

- presents w/ fever and occipital or posterior cervical lymphadenopathy followed by a blanching, erythematous maculopapular rash that spreads in a cranial-caudal pattern (starts on face and spreads to trunk) and SPARES THE PALMS AND SOLES - affected adult women also suffer from arthritis that can last up to a month after resolution of other symptoms - can be contagious for up to 3 wks during incubation period prior to symptomatic manifestation - postinfectious encephalitis is a rare complication that can occur within a week of the exanthem - congenital disease: sensorineural hearing loss, intellectual disability, cardiac anomalies (PDA), cataracts/glaucoma - children: low grade fever, conjunctivitis, coryza, cervical lymphadenopathy, Forschheimer spots, maculopapular rash - diagnosis: PCR, acute and convalescent serology for anti-rubella IgM and IgG - prevention: live attenuated rubella vaccine - tx: supportive

Question 642

measles

Answer 642

- same rash as rubella - high fever (> 104F) and cranial-caudal spread of rash takes days vs less than 24 hrs in rubella - arthritis does not occur

Question 643

Disseminated gonococcal infection

Answer 643

- triad of tenosynovitis, dermatitis, and migratory asymmetric polyarthralgias - vesiculopustular, few in number, and rarely involves the face

Question 644

Rocky Mountain spotted fever

Answer 644

-febrile prodrome followed by an erythematous macular rash that starts over the wrists and ankles, involves the palms and soles, and spreads centrally

Question 645

Secondary syphilis

Answer 645

- fever and maculopapular rash involving the entire trunk and extremities - INCLUDES the palms and soles

Question 646

first-line tx for noninflammatory (comedonal) acne

Answer 646

-Topical retinoids

Question 647

Inflammatory acne

Answer 647

- tx w/ topical retinoids and benzoyl peroxide - moderate to severe inflammatory acne benefits from the addition of topical antibiotics - oral antibiotics and isotretinoin are usually reserved for severe or recalcitrant acne (nodular/cystic acne; severe inflammatory)

Question 648

Idiopathic intracranial HTN (pseudotumor cerebri)

Answer 648

- presents w/ headache, vision changes (blurry or double vision), papilledema, and/or cranial nerve palsies (usually CN VI) - CSF shows increased opening pressure >250 mmHg! and normal studies - most common in young obese women - GH, tetracyclines, and excessive vitamin A and its derivatives can cause it - withdrawal of these meds is tx; also weight loss and acetazolamide for idiopathic causes

Question 649

MS

Answer 649

- usually presents w/ 2 or more distinctive episodes of CNS dysfunction w/ at least some resolution - optic neuritis, Lhermitte's sign, Uhthoff's phenomenon (worse symptoms w/ increased body temp), motor and sensory deficits, and bowel or bladder dysfunction

Question 650

usually cause of NPH?

Answer 650

impaired absorption of CSF

Question 651

Human milk is the ideal form of nutrition for term infants. The major protein source is whey, which is more easily digested than casein and helps to improve gastric emptying. Newborns should be exclusively breastfed (w/ vitamin D supplementation) until 6 months, then slow introduction to solid foods and continued breastfeeding until 1 yr.

Answer 651

.

Question 652

Familial colonic polyposis

Answer 652

- autosomal dominant; mutation in adenomatous polyposis coli (APC) gene - affects both sexes equally - pts have hundreds of adenomas in the colon and have a 100% risk of cancer, if not treated appropriately w/ elective proctocolectomy at time of diagnosis

Question 653

Schistocytes (helmet cells)

Answer 653

- fragmented erythrocytes - occur in microangiopathic hemolytic anemias (DIC, HUS, TTP) and due to RBC destruction by prosthetic cardiac valves - Hemolytic anemias are characterized by a decreased serum haptoglobin level, increased LDH and indirect bilirubin, increased urinary urobilinogen

Question 654

Differential diagnosis of menorrhagia

Answer 654

- Endometriosis: pain w/ menses, dyspareunia, infertility - Fibroids: heavy menses w/ clots, constipation and pelvic pain/heaviness, enlarged uterus - Adenomyosis: dysmenorrhea and pelvic pain, menorrhagia, bulky/globular/tender uterus - Endometrial cancer/hyperplpasia: hx of obesity, nulliparity, or chronic anovulation; irregular, intermenstrual, or postmenopausal bleeding, small, nontender uterus - endometritis: recent instrumentation of the uterus, foul smelling discharge, fever

Question 655

Adenomyosis

Answer 655

- occurs most frequently in parous women age > 40 and typically presents w/ dysmenorrhea, menorrhagia, and pelvic pain - uterus is symmetrically enlarged, globular, and boggy (due to retained blood in uterine musculature) but is usually

Question 656

Endometrial carcinoma and hyperplasia

Answer 656

- often present w/ irregular menstrual bleeding or postmenopausal bleeding - women age > 45 w/ irregular bleeding require an endometrial biopsy to exclude malignancy

Question 657

Endometriosis

Answer 657

- infertility, pain w/ intercourse, and dysmenorrhea - symptoms begin in 20's/30's - does NOT cause uterine enlargement as foci of endometrial glands are outside the uterus

Question 658

Leiomyomas (uterine fibroids)

Answer 658

- benign smooth muscle tumors of the uterus - dysmenorrhea, menorrhagia, and an enlarged uterus, frequently coexist w/ adenomyosis - firm, irregularly enlarged uterus that can vary in size from normal to the size of a full-term gestation - symptoms of mass effect

Question 659

von Willebrand disease (vWD)

Answer 659

- inherited bleeding disorder that causes easy bruising, bleeding, heavy menses, nosebleeds, and excessive bleeding after surgery or delivery - platelet count is normal

Question 660

Bacterial vaginosis

Answer 660

- Gardnerella vaginalis - thin, off-white discharge w/ fishy odor, no inflammation - pH > 4.5, CLUE CELLS, positive whiff test (amine odor w/ KOH) - Metronidazole is tx

Question 661

Trichomoniasis

Answer 661

- Trichomonas vaginalis - thin, yellow-green, malodorous, frothy discharge; VAGINAL INFLAMMATION - pH > 4.5, motile trichomonads - Tx: Metronidazole, treat sexual partner also

Question 662

Candida vaginitis

Answer 662

- Candida albicans - thick "cottage cheese" discharge, vaginal inflammation - normal pH (3.8-4.2), pseudohyphae - Tx: fluconazole

Question 663

Trichomonas infection

Answer 663

- causes vaginal discharge, pruritis, dysuria, and dyspareunia, although it is sometimes asymptomatic - Pts and their sexual partners should be treated w/ oral metronidazole and abstain from sex until tx has been completed to prevent recurrence

Question 664

most effective abx against Trichomonas

Answer 664

-Metronidazole and tinidazole

Question 665

Emphysematous cholecystitis

Answer 665

- common form of acute cholecystitis in elderly diabetic males - arises due to infection of the gallbladder wall w/ gas-forming bacteria - pts typically males 50-70 - predisposing factors: vascular compromise, immunosuppression, gallstones, infection w/ gas-forming bacteria - crepitus in the abdominal wall adjacent to gallbladder is occasionally detectable - abdominal radiograph will show air fluid levels in gallbladder or US shows curvilinear gas shadowing in gallbladder - Tx: immediate fluid and electrolyte resuscitation, early cholecystectomy, and IV abx against gram-positive Clostridium sp (ampicillin-sulbactam, piperacillin-tazobactam, or combo of aminoglycoside or quinolone w/ clindamycin or metronidazole)

Question 666

Acute cholangitis

Answer 666

- infection of the biliary tree; high fever, jaundice, and RUQ pain (Charcot's triad) - arises due to biliary tract obstruction and a resultant bacterial contamination of the bile - causes: choledocholithiasis, biliary tract manipulations/stenting, and hepatobiliary malignancies - alk phos and WBC are often markedly elevated

Question 667

Studies have shown that the risk for sepsis is present up to 30 yrs and probably longer after splenectomy. Current recommendations state the pt should receive anti-pneumococcal, Haemophilus, and meningococcal vaccines several weeks before the operation, and daily oral penicillin prophylaxis for 3-5 yrs following splenectomy

Answer 667

.

Question 668

6 interventions shown to be useful in management of diabetic foot ulcers

Answer 668

1. off-loading 2. debridement 3. wound dressings 4. Abx 5. Revascularization 6. Amputation

Question 669

Always suspect lacunar stroke if a patient presents w/ a limited neurologic deficit. The typical lacunar stroke scenarios are pure motor stroke (posterior limb of internal capsule), pure sensory stroke (thalamus), ataxic-hemiparesis (anterior limp of internal capsule), and dysarthria-clumsy hand syndrome (basis pontis). The principle cause of lacunar stroke is HTN, leading to lipohyalinosis of small vessels.

Answer 669

.

Question 670

CSF analysis in common conditions

Answer 670

- normal: 0-5 WBC, 40-70 glucose, 1000 WBC, 250 protein - Tuberculosis meningitis: 5-1000 WBC, 250 protein - Viral meningitis: 100-1000 WBC, 40-70 glucose,

Question 671

Cryptococcal meningoencephalitis

Answer 671

- IV amphotericin (plus flucytosine) is induction therapy - subacute meningitis, that presents after weeks of symptoms - usually immunocompromised - increased ICP w/ ELEVATED OPENING PRESSURE on spinal tap

Question 672

Chlordiazepoxide

Answer 672

-used to treat alcohol withdrawal in hospitalized pts

Question 673

Viral encephalitis

Answer 673

- CSF findings of elevated WBC counts w/ lymphocytic predominance, normal glucose, and elevated protein concentration - start IV acyclovir

Question 674

Measles (rubeola)

Answer 674

- extremely contagious; spread by droplets from repiratory secretions; virus can remain airborne for several hours - fever, cough, coryza, non-purulent conjunctivitis, and Koplik spots (pathognomonic for measles!; bluish-white lesions) which appear on buccal mucosa and sometimes in conjunctivae and vaginal mucosa - on days 3-5 of ilness, the erythematous, macular exanthem is sometimes pruritic; begins on the face; and spreads in a cephalocaudal and centrifugal pattern to the rest of the body; the rash persists for a week, coalesces, and darkens to a reddish-brown color - diagnosis: 4-fold rise in antibody titers and confirmed by PCR - Tx: symptomatic relief w/ antipyretics and hydration; VITAMIN A can be given to pts who are deficient in this vitamin or hospitalized children at high risk of complications - complications: otitis media, pneumonia, neruologic (encephalitis, acute disseminated encephalomyelitis, subacute sclerosing panencephalitis), gastroenteritis

Question 675

Erythema infectiosum (fifth disease)

Answer 675

- caused by human parvovirus B19 | - children develop fever and an erythematous malar rash ("slapped cheeks")

Question 676

Kawasaki disease

Answer 676

-fever for 5 or more days, mucous membrane changes, extremity changes, nonexudative conjunctivitis, cervical lymph node > 1.5cm, and a polymorphous rash

Question 677

Roseola (exanthema subitum, sixth disease)

Answer 677

- caused by human herpes virus 6 | - maculopapular rash appears as the fever resolves

Question 678

Difference between rubella and measles

Answer 678

- rubella is similar to measles but is relatively mild and shorter in duration - the rubella rash spreads cephalocaudally but does not darken as does measles - the fever is also lower and no Koplik spots are seen

Question 679

The initial step in the management of children w/ speech delay is an audiology evaluation

Answer 679

.

Question 680

the incidence of vertical transmission of HCV infection is ~ 2-5%. All pts w/ chronic hepatitis C infection, including pregnant women, should be immunized against hepatitis A and B if they are not already immune.

Answer 680

.

Question 681

When hemorrhage occurs, tachycardia and peripheral vascular constriction are the first physiological changes! These responses act to maintain the blood pressure within normal limits until severe blood loss has occurred.

Answer 681

.

Question 682

The SBP in hemorrhagic shock begins to decrease in Class II but does not significantly decrease until at least 30% of the intravascular volume has been lost (Class III and IV)

Answer 682

.

Question 683

The immediate management of splenic trauma caused by blunt abdominal injury depends on the pts hemodynamic status and response to fluids (SBP > 100). If pt is initially hemodynamically unstable but improves w/ fluid administration, the best next step is to obtain an abdominal CT scan. If pt is initially hemodynamically unstable and is unresponsive to fluid administration, then emergent exploratory laparotomy is required.

Answer 683

.

Question 684

Positive pressure mechanical ventilation increases intrathoracic pressure, which decreases venous return to the heart and thereby decreases the ventricular preload. In pts w/ hypovolemic shock, this effect may cause circulatory collapse if the pts intravascular volume is not replaced before mechanical ventilation is attempted.

Answer 684

.

Question 685

Lyme disease

Answer 685

- results from the transmission of the spirochete Borrelia burgdorferi from Ixodes tick bites to humans - Pts traveling to tick-infested areas should be advised to wear permethrin-treated pants and long-sleeved shirts, to apply insect repellents to the skin, and to check the entire body for ticks

Question 686

The antidepressant of choice for depressed pts who do not respond to first-line tx w/ a SSRI is another medication in the same class. If still no response or side effects after 2 trials, then switch to different class of antidepressant.

Answer 686

.

Question 687

brief psychotic disorder

Answer 687

-positive psychotic symptoms lasting at least 1 day but less than 1 month

Question 688

The duration of schizophreniform disorder is more than 1 month and less than 6 months; schizophrenia requires duration of at least 6 months

Answer 688

.

Question 689

Delusional disorder

Answer 689

- involves one or more delusions and the absence of other psychotic symptoms in an otherwise high-functioning individual - > 1 month duration

Question 690

Breech presentation

Answer 690

- palpation of the vertex at the fundus indicates fetus is breech - a breech diagnosed before the 37th week of gestation does NOT require any intervention, as they often convert to vertex before the 37th week - external cephalic version is indicated if breech presentation is persistent after 37 weeks, and if this fails, then planned C-section is indicated

Question 691

Patients w/ Turner syndrome have ovarian dysgenesis and poor ovarian function; FSH should be high due to lack of negative feedback

Answer 691

.

Question 692

Acute exacerbations of MS are treated with what?

Answer 692

- corticosteroids - beta-interferon or glatiramer acetate is used to decrease the frequency of exacerbations in pts w/ relapsing-remitting or secondary progressive form of MS; however, they have no proven role in the tx of acute exacerbations

Question 693

Vitamin B12 deficiency is common after a total or partial gastrectomy. Vitamin B12 is a necessary cofactor in purine synthesis, and its deficiency causes defective DNA synthesis. This results in ineffective erythropoiesis, presenting as megaloblastic anemia

Answer 693

.

Question 694

gold standard for diagnosis of OSA?

Answer 694

Nocturnal polysomnography

Question 695

Congenital hypothyroidism

Answer 695

- associated w/ neurodevelopmental injury if not recognized and treated early - decreased activity, hoarse cry, and jaundice are commonly associated w/ congenital hypothyroidism, but the majority of infants w/ congenital hypothyroidsim are asymptomatic - thyroid dysgenesis is the most common cause worldwise - tx: levothyroxine immediately to prevent neurodevelopmental injury

Question 696

what screening STI tests are recommended for all pregnant women regardless of their risk factors for STIs?

Answer 696

Syphylis, HIV, and hepatitis B

Question 697

Viral infections may present w/ symmetric arthritis. Viral arthritis is distinguished from rheumatoid arthritis and other causes of symmetric arthritis by its acute onset, lack of elevated inflammatory markers, and resolution within 2 months. Parvovirus is most common cause.

Answer 697

.

Question 698

Polymyalgia rheumatica

Answer 698

- pain and stiffness of pelvis and shoulders | - markedly elevated ESR

Question 699

Fibromyalgia

Answer 699

- chronic, diffuse MSK pain syndrome most common in females - often accompanied by fatigue, mood disorders, insomnia, abdominal pain, and IBS - diagnosis depends on tenderness in at least 11 of 18 defined trigger sites

Question 700

Amebiasis

Answer 700

- should be considered in pts w/ a liver abscess who have lived or traveled in an endemic area for Entamoeba histolytica - initial evaluation includes imaging, serologic testing, and empiric tx w/ metronidazole (to treat the abscess) and a luminal agent (to eradicate intestinal colonization). - cyst drainage is not recommended routinely

Question 701

Simple renal cysts

Answer 701

- almost always benign and do not require further evaluation - features concerning for malignant renal mass: multilocular mass, irregular walls, thickened septae, and contrast enhancement

Question 702

Bacillus cereus

Answer 702

- causes nausea and vomiting after eating rice | - symptom onset is within one to six hours

Question 703

Staphylococcus aureus toxin

Answer 703

- present in foods such as dairy, salad, meat, and eggs - N/V/D and abdominal pain - rapid onset of symptoms due to preformed toxin

Question 704

Clostridium perfringens

Answer 704

- spore forming organism - spores germinate in foods such as meats, poultry, or gravy - watery diarrhea due to production of toxin in gut - symptom onset is later than with preformed toxin (8-14 hrs after ingestion)

Question 705

common complication of pts w/ sickle cell trait?

Answer 705

painless hematuria is most common; may also develop isosthenuria (impairment in concentrating ability); increased risk of UTI in pregnancy; splenic infarct possible at high altitudes

Question 706

Hemi-sensory loss w/ severe dysesthesia (thalamic pain phenomenon) of the affected are is typical for a THALAMIC stroke in the VPL nucleus

Answer 706

.

Question 707

Carcinoid syndrome

Answer 707

- presents w/ episodic flushing, secretory diarrhea, wheezing, and murmur of tricuspid regurgitation - elevated 24 hr urinary 5-HIAA can confirm the diagnosis in most pts

Question 708

facial nerve (CN VII)

Answer 708

- responsible for facial movement, taste in the anterior 2/3 of the tongue, lacrimation (via the greater petrosal/vidian nerves), salivation (via chorda tympani), and eyelid closure - also carries sensory fibers supplying sensation to parts of the external ear and the nasopharynx

Question 709

Oculomotor nerve (CN III)

Answer 709

-responsible for the majority of eye movement (adduction via the medial rectus, elevation via the superior rectus and inferior oblique, and depression via the inferior rectus), eyelid opening, and pupillary constriction

Question 710

Optic nerve (CN II)

Answer 710

-carries visual info to the brain as well as mediates the afferent limb of the pupillary light reflex pathway

Question 711

vagus nerve (CN X)

Answer 711

- swallowing, palate elevation, phonation, and parasympathetic outflow to the thoracoabdominal viscera, including monitoring the aortic arch baro- and chemoreceptors - also responsible for taste in the epiglottis and sensation from parts of the external ear; also mediates the afferent limb of the cough reflex and efferent limb of gag reflex

Question 712

Isolated systolic hypertension

Answer 712

- important cause of HTN in elderly pts, and its caused by decreased elasticity of the arterial wall - should always be treated due to its association w/ an increased risk for cardiovascular events - initial tx involves monotherapy w/ a low-dose thiazide, an ACE inhibitor, or a long-acting calcium channel blocker

Question 713

ARDS

Answer 713

- form of non-cardiogenic pulmonary edema caused by leaky alveolar capillaries - causes include: sepsis, severe infection, severe bleeding, toxic ingestions and burns - mechanical ventilation w/ low tidal volumes (6 ml/kg) and PEEP can improve oxygenation - potential complications of PEEP include barotrauma and tension pneumothorax

Question 714

Based on urinary chloride levels and ECF volume status, metabolic alkalosis can be classified as saline-responsive and saline-unresponsive. Saline-responsive metabolic alkalosis is associated w/ low urinary chloride excretion and volume contraction, and corrects w/ saline infusion alone. Saline-unresponsive metabolic alkalosis typically presents w/ urinary chloride > 20 mEq/L. Name some causes of each.

Answer 714

- Saline unresponsive (> 20 mEq/L): can have expanded ECF w/ hypervolemia (primary hyperaldosteronism, Cushing syndrome, excessive black licorice ingestion, ectopic ACTH production) or appear hypo/euvolemic (Bartter syndrome, Gitelman syndrome) - Saline responsive (

Question 715

All forms of renal tubular acidosis cause a non-anion gap metabolic acidosis.

Answer 715

.

Question 716

Primary hyperaldosteronism

Answer 716

-increases urinary H+ and K+ excretion to cause metabolic alkalosis. Pts also typically develop HTN, expanded ECF volume, and hypokalemia. Urine Cl- is usually > 20 mEq/L as there is no stimulus for renal NaCl retention.

Question 717

Most antidepressants must be taken for 4-6 weeks before they provide symptomatic relief.

Answer 717

.

Question 718

Breastfed infants

Answer 718

- decreased risk of developing otitis media, respiratory, GI, and UTIs; and necrotizing enterocolitis - lower rates of type 1 DM and childhood cancer - the only absolute infant contraindication to breastfeeding is galactosemia

Question 719

Management of hepatic encephalopathy

Answer 719

- supportive care, tx the precipitating cause (volume depletion, electrolyte abnormalities), and lowering serum ammonia - Disaccharides (lactulose, lactitol) are initially preferred for lowering serum ammonia - Rifaximin can be added to lactulose in pts w/o improvement after 48 hrs or used as monotherapy in those unable to take lactulose

Question 720

most common causes of brain metastases

Answer 720

- Lung, breast, unknown primary, melanoma, colon, and renal cell carcinoma - Lung cancer is most common cause of brain metastasis in pts w/ a hx of smoking and no prior incidence of cancer - tumors that RARELY metastasize to the brain include prostate cancer, esophageal cancer, oropharyngeal carcinoma, hepatocellular carcinoma, and non-melanoma skin cancers - Brain mets from breast, colon, and renal cell usually have SOLITARY brain mets - Lung cancer and malignant melanoma can present w/ multiple brain mets

Question 721

Glioblastoma multiforme

Answer 721

- primary CNS tumor arising within the brain parenchyma | - usually presents as solitary mass w/ central necrosis and extensive vasogenic edema

Question 722

Ankylosing spondylitis (AS)

Answer 722

- occurs most often in adults aged 20-30 years - Pts suffer from limited spine mobility and progressive back pain of greater than 3 months duration - the pain and stiffness are worse in the morning and improve w/ exercise - Bilateral sacroiliitis on plain film of a pt w/ suspected symptoms is diagnostic - the most prominent extraarticular manifestation of AS is ANTERIOR UVEITIS

Question 723

Thoracic aortic aneurysm

Answer 723

-associated w/ Marfan syndrome, Ehlers-Danlos syndrome, and syphilis; also inflammatory arthritides

Question 724

Episcleritis is most strongly associated w/ what?

Answer 724

Rheumatoid arthritis and inflammatory bowel disease

Question 725

Oral ulcers are associated w/ what?

Answer 725

SLE, Crohn's, Behcet's

Question 726

SIADH

Answer 726

- common complication of small cell lung cancer | - initial tx is fluid restriction to

Question 727

Pneumococcal vaccination plus penicillin prophylaxis can prevent almost all cases of pneumococcal sepsis in pts w/ sickle cell disease. 2x daily administration of prophylactic penicilline should be given to kids w/ sickle cell disease until the age of 5.

Answer 727

.

Question 728

Acute liver failure

Answer 728

- most often due to acute viral hepatitis, acetaminophen toxicity, and ischemic hepatopathy - acute onset of markedly elevated transaminases (often in the thousands), reduced hepatic synthetic function, and encephalopathy

Question 729

Acute alcoholic hepatitis and nonalcoholic steatohepatitis usually cause mild to moderate AST and ALT elevations that rarely exceed 500 U/L. In additions, alcoholic hepatitis typically occurs in pts who drink heavily (> 100g/day) and classically produces an AST/ALT ratio > 2:1.

Answer 729

.

Question 730

Liver metastasis

Answer 730

most often due to breast cancer, small cell lung cancer, and lymphoma

Question 731

Infectious mononucleosis

Answer 731

- most commonly caused by the Epstein-Barr virus and presents w/ fever, fatigue, exudative pharyngitis, and diffuse cervical lymphadenopathy - a polymorphous, maculopapular rash frequently develops after administration of amoxicillin - pts should avoid sports for >3 wks due to risk of splenic rupture

Question 732

Adenoviruses

Answer 732

- frequent causes of upper respiratory infections and typically present w/ coryza, pharyngitis, tonsillitis, and conjunctivitis - other manifestations: fever, malaise, headache, and abdominal pain

Question 733

Coxsackie virus

Answer 733

-can cause hand-foot-mouth disease and herpangina (vesicles on the hard palate)

Question 734

Group A beta-hemolytic strep

Answer 734

- responsible for 15-30% of cases of pharyngitis in children | - fever, exudative pharyngitis, and enlarged anterior cervical lymph nodes

Question 735

Chikungunya fever

Answer 735

- mosqutio-borne viral illness (Aedes mosquito) that typically presents w/ flulike illness, symmetric polyarthralgias, macular or maculopapular rash on the limbs and trunk, peripheral edema, and cervical lymphadenopathy - tx is supportive, lasts 7-10 days - lymphopenia and thrombocytopenia

Question 736

Reactive arthritis

Answer 736

-usually presents 1-4 wks after a GI or GU infection w/ asymmetric oligoarthritis, conjunctivits, and oral lesions

Question 737

Postoperative cholestasis

Answer 737

- can develop after a prolonged surgery characterized by hypotension, extensive blood loss into tissues, and massive blood replacement - bilirubin and alk phos are elevated

Question 738

Recurrent chalazion

Answer 738

- requires histopathologic exam because there is a risk for an underlying sebaceous (meibomian gland) carcinoma - additionally, basal cell carcinoma is the most common malignancy of the lid margin, and may appear clinically similar to a chalazion

Question 739

management of myasthenia crisis w/ respiratory failure consists initially of endotracheal intubation followe by tx w/ corticosteroids as well as IVIG or plasma exchange (preferred)

Answer 739

.

Question 740

The lupus anticoagulant, an anti-phospholipid antibody, is a pro-thrombotic immunoglobulin that causes a spuriosly prolonged partial thromboplastin time in vitro.

Answer 740

.

Question 741

Antiphospholipid syndrome

Answer 741

1. Venous thromboembolism or recurrent early miscarriages 2. presence of an antiphospholipid antibody such as the lupus anticoagulant, anticardiolipin antibody, or beta 2 glycoprotein 1 antibody

Question 742

Always suspect multiple sclerosis (MS) in a female w/ multiple neurologic presentations that are interspaced between time periods. Optic neuritis can result in blurring of vision, and is often associated w/ retrobulbar pain.

Answer 742

.

Question 743

Trousseau's syndrome (migratory superficial thrombophlebitis)

Answer 743

- hypercoagulability disorder presenting w/ recurrent and migratory superficial thrombophlebitis at unusual sites (eg arm, chest area) - usually associated w/ an occult VISCERAL malignancy such as pancreatic (most common), stomach, lung, or prostate carcinoma

Question 744

Arterial occlusion of an extremity will cause pain, pulselessness, pallor, paresthesias, and paralysis in the affected limb. Embolic occlusion classically causes sudden-onset severe pain and asymmetric pulselessness.

Answer 744

.

Question 745

coarctation of the aorta

Answer 745

- HTN in the upper part of the body and relative hypoperfusion in the lower part of the body - a mild, continuous murmur heard all over the chest is due to the development of collaterals between the hypertensive and hypoperfused vessels - RIB NOTCHING, caused by the dilatation of the collateral chest wall vessels, is specific for coarctation

Question 746

Penile fracture

Answer 746

-surgical emergency that requires emergent urethral imaging and surgical repair

Question 747

Pts w/ upper GI bleeding who have a depressed level of consciousness and ongoing hematemesis should be intubated to protect the airway as a part of initial stabilization and resuscitation. Prompt enoscopic tx w/ band ligation or sclerotherapy should then be performed to stop the bleeding.

Answer 747

.

Question 748

Torsades de pointes (TdP)

Answer 748

- refers to polymorphic ventricular tachycardia that occurs in the setting of a congenital or acquired prolonged QT interval - immediate defibrillation is indicated in hemodynamically unstable pts w/ TdP, while IV magnesium is first-line for stable pts w/ recurrent episodes of TdP

Question 749

Adenosine

Answer 749

- acute termination of paroxysmal SUPRAventricular tachycardia (PSVT) - NOT recommended for tx of ventricular tachycardia

Question 750

Amiodarone

Answer 750

- class III anti-arrhythmic (K+ blocker) - used for BOTH atrial and ventricular tachycardia - used occasionally in pts w/ polymorphic VT (and normal baseline QT interval) due to myocardial ischemia or infarction

Question 751

Atropine

Answer 751

-used in tx of symptomatic SINUS BRADYCARDIA or AV NODAL BLOCK

Question 752

Calcium gluconate

Answer 752

- useful for pts w/ cardiotoxicity due to hyperkalemia - occasionally used in pts w/ beta-blocker and/or calcium channel blocker overdose - ECG of pts w/ hyperkalemia shows peaked T waves, followed by lengthening of the PR and QRS intervals, eventually resulting in a sine wave

Question 753

Sodium bicarb

Answer 753

useful in management of pts w/ TdP due to quinidine use; also those in cardiac arrest from metabolic acidosis, hyperkalemia, or TCA overdose

Question 754

Sotalol

Answer 754

- class III antiarrhythmic | - causes QT prolongation and TdP

Question 755

signs and symptoms of PE

Answer 755

- nonspecific and highly variable - suspect in any pt who presents w/ some comb of sudden-onset SOB, pleuritic chest pain, low-grade fever, and hemoptysis - tachypnea, tachycardia, and hypoxemia are common exam findings - calf swelling and Virchow's triad (stasis, endothelial injury, and hypercoagulable state) are not always present in PE - ECG: S1Q3T3 - CXR: Hampton's hump, Westermark's sign)

Question 756

Genital ulcers

Answer 756

- Painful: Herpes simplex virus (MULTIPLE small, grouped ulcers w/ erythematous base; shallow; tender lymph nodes; most common in US; recurrence is common) and Haemophilus ducreyi (chancroid)(single or multiple deep ulcers, often w/ irregular/ragged border; base may be friable and have gray/yellow exudate; matted lymph nodes which can suppurate/rupture) - Painless: Treponema pallidum (syphilis)(single, indurated, well-circumscribed painless ulcer known as CHANCRE; clean base; nontender lymph nodes), Chlamydia trachomatis serovars L1-3 (LGV)(small and shallow ulcers often absent; matted lymph nodes; large, painful, fluctuant BUBOES; sinus tracts), and Klebsiella granulomatis (granuloma inguinale)(extensive and progressive nodules--> ulcers/beefy-appearing lesions w/ bleeding; base may have granulation like tissue)

Question 757

Anti-D immune globulin

Answer 757

- should be administered to any Rh D-negative mother who delivers an Rh D-positive baby - the standard dose is usually adequate at 28 wks gestation - after delivery or procedures, the Kleihauer-Betke test is used to determine whether a higher dose is needed due to the increased risk of fetal blood cells entering the maternal circulation

Question 758

Bite cells and Heinz bodies

Answer 758

-Glucose-6-phosphate dehydrogenase deficiency

Question 759

type of RBC in autoimmune hemolysis

Answer 759

Spherocytes

Question 760

First step in managing caustic ingestions

Answer 760

- assessing ABCs - contaminated clothing should be removed promptly - upper GI endoscopy is the diagnostic study of choice to evaluate the extent of injury and should be done within 24 hrs - attempting to neutralize the alkali w/ vinegar or lavage is dangerous as these interventions may trigger vomiting, which may cause further mucosal damage - all pts w/ persistent dysphagia or significant esophageal burns on endoscopy should undergo barium contrast studies 2-3 weeks after ingestion to assess for ESOPHAGEAL STRICTURES or PYLORIC STENOSIS

Question 761

Ewing's sarcoma

Answer 761

-often confused w/ osteomyelitis; however, x-ray findings of lamellated appearance or "onion-skin" periosteal rxn; lytic, central lesion accompanied by endosteal scalloping; often followed w/ a "moth-eaten" or mottled appearance and extension into soft tissue

Question 762

Osteomyelitis

Answer 762

- fever, malaise, local joint pain, and swelling | - chronic osteomyelitis: central lytic bone defect w/ surrounding sclerosis termed as Brodie's abscess

Question 763

Precision

Answer 763

- measure of random error - the tighter the confidence interval, the more precise the result - increasing the sample size increases precision

Question 764

Validity and accuracy

Answer 764

- measures of systematic error (bias) - accuracy is reduced if the result does not reflect the true value of the paramater measured - increasing the sample size increases the precision of the study, but does not affect accuracy

Question 765

Physiologic jaundice of the newborn

Answer 765

- common and usually benign; resolve on its own by age 1-2 weeks - the indirect hyperbilirubinemia is due to increased bilirubin production, decreased bilirubin clearance, and increased enterohepatic recycling - phototherapy is the gold standard tx for rapidly rising hyperbilirubinemia to prevent kernicterus

Question 766

biliary atresia

Answer 766

- jaundice is usually the first sign - the neonatal liver can conjugate bilirubin, but the obstructed biliary tract cannot transport bile to the intestine, resulting in hepatic bile retention (cholestasis), direct hyperbilirubinemia, and jaundice - direct hyperbilirubinemia is defined as conjugated bilirubin > 2mg/dL or > 20% of total bilirubin

Question 767

The most common cause of CNS mass lesions in AIDS pts?

Answer 767

- Toxoplasmosis - TMP-SMX is used for PROPHYLAXIS - Sulfadiazine and pyrimethamine are used for TREATMENT purposes

Question 768

Uncomplicated cystitis tx

Answer 768

- TMP-SMP - Nitrofurantoin - Fosfomycin

Question 769

Complicated cystitis tx (diabetes, CKD, pregnancy, immunocompromised, obstruction, hospital-acquired, procedural associated, indwelling foreign body)

Answer 769

-oral fluoroquinolones, IV ceftriaxone if more severe

Question 770

Pyelonephritis tx

Answer 770

- stable: oral fluoroquinolones | - severe: IV ceftriaxone

Question 771

Bupropion

Answer 771

contraindicated in pts w eating disorders as it can provoke seizures

Question 772

most widely used antipsychotic for anorexia nervosa tx?

Answer 772

Olanzapine | -can be considered in pts who fail to gain weight despite initial nutritional rehab and CBT

Question 773

Raloxifene

Answer 773

- mixed agonist/antagonist of estrogen receptors - in breast and vaginal tissue, its an ANTAGONIST; whereas in bone, its an AGONIST - first line agent for prevention of osteoporosis, and it DECREASES breast cancer risk - INCREASES risk of thromboemolism

Question 774

Tamoxifen increases risk for what type of cancer?

Answer 774

Endometrial cancer

Question 775

All depressed pts (at least 5 of SIGECAPS for 2 wks) should be screened for suicidal ideation. Then ask if they have a specific plan, if so, hospitalize.

Answer 775

.

Question 776

IgA nephropathy

Answer 776

- most common cause of glomerulonephritis in adults - pts have recurrent episodes of gross hematuria, usually within 5 days after a URI (SYNPHARYNGITIC) - differentiated from postinfectious glomerulonephritis based on earlier onset of URI-related GN and normal serum complement levels - kidney biopys can also help differentiate (IgA deposits in mesangial cells vs subepithelial humps of C3 complement)

Question 777

Acute interstitial nephritis

Answer 777

- acute inflammatory process involving the renal tubules and interstitium following exposure to a drug (abx, NSAIDs, PPIs). - other findings: fever, skin rash, eosinophilia, eosinophiluria, or WBC casts

Question 778

Alport syndrome

Answer 778

- X-linked defect in collagen-IV (basement membranes) formation and present w/ hearing loss, ocular abnormalities, hematuria, and progressive renal insufficiency - thinning of glomerular BMs

Question 779

Anti-GBM disease

Answer 779

- anti-GBM antibodies against collagen IV (alpha-5 chain) damaging the glomeruli and alveolar lining - can be renal limited process (rapidly progressive GN) or alveolar hemorrhage (pulmonary renal syndrome) - Goodpasture's syndrome refers to pulmonary-renal syndrome that is a manifestation of anti-GBM disease

Question 780

Benign recurrent hematuria

Answer 780

- thin BM nephropathy | - benign familial condition that presents as isolated microscopic hematuria

Question 781

Henoch-Schonlein purpura

Answer 781

- systemic form of IgA involvement of the glomeruli, skin, joints, and intestines - more common in children and presents as erythematous and papular skin rash invovling the dorsal aspect of lower extremities, abdominal pain, arthralgia/arthritis, and microscopic hematuria/proteinuria

Question 782

Lupus nephritis

Answer 782

- nephritis syndrome, nephrotic syndrome, RPGN, or pulmonary-renal syndrome - low complement levels (C3 and C4) and positive lupus antibodies (ANA, anti-dsDNA, anti-Smith)

Question 783

Dementia w/ Lewy bodies

Answer 783

- usually associated w/ Parkinsonian symptoms - gradually progressive dementia w/ fluctuations in cognitive function, persistent and well-formed visual hallucinations, and EPS

Question 784

Huntington's disease

Answer 784

- autosomal dominant; affects caudate and putamen - mean onset age 35-44 - choreoathetoid movements, behavioral disturbances, and dementia

Question 785

Sudden onset of abdominal pain, fetal heart rate abnormalities, and recession of the presenting part during active labor indicated what?

Answer 785

probable uterine rupture | -risk factors include a pre-existing uterine scar or abdominal trauma

Question 786

small cervical lymph nodes are a common observation in children and young adults. Pts w/ asymptomatic, soft lymph nodes can be observed for node growth or the development of symptoms.

Answer 786

- small, rubbery lymph nodes are rarely pathologic; nodes les than 1 cm are almost always benign - nodes > 2 cm are associated w/ greater likelihood of malignancy or granulomatous disease

Question 787

Inhaled anti-muscarinic agents such as ipratropium are the mainstay of symptom management in COPD. These anti-cholinergic meds may be combined w/ short acting beta agonists for greater symptom relief

Answer 787

.

Question 788

the most common causes of hyperkalemia include acute or chronic kidney disease, meds, or disorders impairing the renin-angiotensin axis. Common offending meds include nonselective beta blockers, potassium sparing diuretics (triamterene), ACE inhibitors, ARBs, and NSAIDS

Answer 788

.

Question 789

Modified Wells criteria can assess pretest probability of acute P, as it can have variable presentaitons. Pts w/ likely PE based on these criteria should be further evaluated w/ CTA.

Answer 789

.

Question 790

Aortic regurgitation

Answer 790

-produces an early diastolic murmur and can be associated w/ several physical signs caused by a hyperdynamic pulse, including bounding or "water hammer" peripheral pulses

Question 791

PID

Answer 791

- may lead to tubo-ovarian abscess, abscess rupture, pelvic peritonitis, and sepsis if left untreated - inability to take oral meds due to nausea and vomiting is an indication for inpatient tx of PID

Question 792

Tx of hepatic encephalopathy

Answer 792

lactulose, rifaximin, and laxatives

Question 793

Prolonged gastric acid suppression w/ PPIs or Histamine 2 receptor blockers is a risk factor for C. diff infection. The diagnosis of C. difficile colitis can be confirmed w/ a stool assay for toxins A and B

Answer 793

.

Question 794

Serum gastrin levels

Answer 794

-may be measured in pts w/ suspected gastrinoma and Zollinger-Ellison syndrome (recurrent duodenal ulcers, gastroesophageal reflux, diarrhea)

Question 795

The presence of a systolic-diastolic abdominal bruit in a patient w/ HTN and atherosclerosis is strongly suggestive of what?

Answer 795

Renal artery stenosis

Question 796

DKA

Answer 796

- main precipitating factor is omission of insulin w/ or w/o infections or other stressors - affects type 1 diabetics - diagnosis: blood glucose > 250 mg/dL, pH

Question 797

Succinylcholine

Answer 797

- depolarizing neuromuscular blocker that can cause life-threatening hyperkalemia! - it should NOT be used in pts w/ or at high risk for hyperkalemia, such as burn and crush injury pts and pts w/ prolonged demyelination!

Question 798

Hypersensitivity pneumonitis (HP)

Answer 798

- inflammation of the lung parenchyma caused by antigen exposure - acute episodes present w/ cough, breathlessness, fever, and malaise that occur within 4-6 hours of antigenic exposure - chronic exposure may cause weight loss, clubbing, and honeycombing of the lung - cornerstone of management is avoidance of the responsible antigen - may develop to pulmonary fibrosis and a RESTRICTIVE pattern on lung spirometry - eg "bird fancier's lung" and "farmer's lung"

Question 799

Diaphragmatic rupture

Answer 799

- more common on the left side because of the right side tends to be protected by the liver - pts have respiratory distress and can have deviation of the mediastinal contents to the opposite side - elevation of the hemidiaphragm on the CXR might be the only abnormal finding - CXR showing NG tube in pulmonary cavity is diagnostic

Question 800

Causes of hyponatremia include SIADH and primary polydipsia. Primary polydipsia?

Answer 800

- more common in pts w/ psych conditions, possible due to a central defect in thirst regulation - pts typically develop hyponatremia and dilute urine w/ urine osmolality

Question 801

Hydrocele

Answer 801

- fluid collection within the processus or tunica vaginalis (the peritoneal projection that accompanies the testis during its descent into the scrotum) - when processus vaginalis fails to obliterate, peritoneal fluid may accumulate within the processus causing a COMMUNICATING hydrocele - a collection of fluid within the tunica vaginalis that has properly obliterated its communication w/ the peritoneum is a NON-COMMUNICATING hydrocele - hydroceles will transilluminate, while other masses will note - most will resolve spontaneously by age of 12 months and can be safely observed during that period - hydroceles that do not resolve spontaneously should be removed surgically due to risk of inguinal hernia

Question 802

Diagnostic testing for coronary artery disease (CAD)

Answer 802

- should NOT be performed in low-risk pts as they frequently have false-positive test results - Pts w/ intermediate probability of CAD should receive appropriate stress testing based on ECG findings and their ability to exercise - high-risk pts should be started on appropriate medical therapy, w/ expert evaluation to consider coronary angiography

Question 803

Lithium should NOT be administered to pts w/ renal dysfunction. Valproic acid, w/ or w/o an antipsychotic, is suitable alternate therapy for the initial tx of bipolar disorder, manic or mixed-phase.

Answer 803

.

Question 804

Laboring pts w/ placental abruption > 34 wks may be allowed to deliver vaginally if the woman and fetus are stable. Cesarean delivery is indicated if mother is hypotensive w/ severe bleeding or if the condition of the fetus deteriorates.

Answer 804

.

Question 805

Pts w/ decreased fetal movement should undergo antenatal fetal testing starting w/ a nonstress test (NST) followed by a contraction stress test (CST) or biophysical profile (BPP) if the NST is nonreactive. a CST can be performed if there is no contraindication to labor. Fetal heart decelerations during spontaneous or induced contractions are concerning for fetal compromise.

Answer 805

.

Question 806

A normal contraction stress test indicates that fetal compromise is unlikely. The chance of fetal death within 1 week of a normal test is rare; antepartum fetal testing may be repeated 1 week later.

Answer 806

.

Question 807

Iron deficiency anemia

Answer 807

- most common nutritional deficiency in children, often caused by excessive intake of cow's milk (> 24 oz a day) and results in a microcytic anemia - can be differenitiated from thalassemia by an elevated RDW, which is typically > 20% in iron deficiency

Question 808

Tx of choice for early localized Lyme disease in children

Answer 808

- Oral amoxicillin - Oral doxycycline, amoxicillin, and cefuroxime have equivalent efficacy. Doxy is usually used because it can also treat possible co-infection w/ Anaplasma phagocytophilum in Ixodes tick bites, but should not be used in children

Question 809

Lyme meningitis and heart block tx

Answer 809

-IV ceftriaxone

Question 810

most common predisposing factor for acute bacterial sinusitis?

Answer 810

a preceding viral upper respiratory infection | -tx: amoxicillin plus clavulanic acid

Question 811

somatic symptom disorder

Answer 811

-excessive anxiety and preoccupation w/ 1 or more unexplained symptoms

Question 812

illness anxiety disorder

Answer 812

-fear of having a serious illness despite few or no symptoms and consistently negative evaluations

Question 813

conversion disorder (functional neurologic symptom disorder)

Answer 813

- neurologic symptom incompatible w/ any known neurologic disease; often acute onset associated w/ stress - symptoms NOT PRODUCED INTENTIONALLY - severe enough to cause social and functional impairment, although pts may appear indifferent ("la belle indifference")

Question 814

factitious disorder

Answer 814

-intentional falsification or inducement of symptoms w/ goal to assume SICK ROLE

Question 815

Malingering

Answer 815

-falsification or exaggeration of symptoms to obtain external incentives (SECONDARY GAIN)

Question 816

Somatic symptom disorder

Answer 816

- inovles one or more somatic complaints (including pain) that are distressing or result in significant disruption of daily life, w/ excessive thoughts, feelings, or behaviors related to these symptoms and lasting 6 or more months - pts may have concurrent medical illness, or the symptoms may represent normal bodily function

Question 817

Pregnant women w/ HGSIL on Pap testing should be evaluated w/ colposcopy. If the initial colposcopy is negative, repeat cytology and colposcopy are recommended after delivery. Cervical biopsy and loop electrosurgical excision procedure are NOT performed during pregnancy unless there is a lesion suggestive of invasive cancer.

Answer 817

.

Question 818

Lewy body dementia

Answer 818

-fluctuating cognitive impairment, recurrent visual hallucinations and motor features of Parkinsonism

Question 819

Acute aortic dissection

Answer 819

- high mortality rate and requires rapid diagnosis - effective and less invasive modalities for rapid diagnosis include TEE, and CT; TEE is preferred over CT scan in pts w/ kidney disease due to risk of contrast-induced nephropathy

Question 820

Contrast-induced nephropathy

Answer 820

- transient spike in Cr within 24 hrs of contrast administration, w/ a return to normal renal function within 5-7 days - Pts w/ diabetes and elevated baseline Cr are at especially high risk - adequate IV hydration w/ isotonic bicarb or normal saline and administration of N-acetylcysteine help to minimize the risk of contrast-induced nephropathy

Question 821

Viridans group streptococci (most commonly S. mutans) are the most common causes of endocarditis following dental procedures. Other viridans group: S. mitis, S. sanguis, S. salivarius

Answer 821

,

Question 822

Strep bovis

Answer 822

- normal inhabitant of the GI tract, and S. bovis bacteremia is associated w/ colon cancer - colonoscopy should be performed when this organism is isolated from blood cultures

Question 823

risk factors for Group B strep endocarditis

Answer 823

-DM, carcinoma, alcoholism, hepatic failure, elective abortion, and IV drug use

Question 824

Oliguria, azotemia, and an elevated BUN/Cr ratio > 20:1 in post-op state most likely indicate acute pre-renal failure from hypovolemia, though urinary catheter obstruction should first be ruled out. The next step in the diagnosis/management of acute renal failure manifesting as oliguria or anuria is an IV fluid challenge.

Answer 824

.

Question 825

Strongest predictors of abdominal aortic aneurysm expansion and rupture

Answer 825

- Large aneurysm diameter, rapid rate of expansion, and current cigarette smoking - current indiations for operative or endovascular repair include aneurysm size > 5.5 cm, rapid rate of aneurysm expansion (> 0.5cm in 6 months or > 1 cm per year), and presence of symptoms (abdominal, back, or flank pain; lim ischemia) regardless of aneurysm size

Question 826

Buproprion is FDA-approved for smoking cessation. It should be used in conjunction w/ counseling and nicotine replacement.

Answer 826

.

Question 827

Anabolic steroid use by a man

Answer 827

-can produce infertility by suppressing the production of GnRH, LH, and FSH

Question 828

Klinefelter syndrome

Answer 828

- XXY (seminiferous tubule dysgenesis) - inherited disorder characterized by testicular fibrosis (primary hypogonadism), azoospermia, gynecomastia, decreased intelligence, increased axial skeletal growth, and high FSH and LH levels

Question 829

Myotonic dystrophy

Answer 829

-testicular atrophy as well as widespread muscular atrophy, weakness, lower-than-normal testosterone levels, and high FSH and LH levels

Question 830

Varicocele

Answer 830

-"bag of worms" sensation on palpation

Question 831

P-value

Answer 831

-probability of observing a given (or more extreme) result due to chance alone, assuming the null hypothesis is true

Question 832

A 95% confidence interval that contains 1.0 would mean that the results are NOT statistically significant

Answer 832

.

Question 833

Graft-versus-host-disease

Answer 833

- caused by recognition of host major and minor HLA-antigens by donor T-cells and consequent cell-mediated immune response - organs typically affected include the skin, intestine, and liver

Question 834

In acute appendicitis, the initial peri-umbilical pain is referred pain and visceral in nature; however, pain shifts to the right lower quadrant w/ involvement of the parietal peritoneum and becomes somatic in nature.

Answer 834

.

Question 835

Multiple endocrine neoplasia (MEN)

Answer 835

- type 1: primary hyperParathyroidism, enteroPancreatic tumors, Pituitary tumors (PPP); due to mutations in then MEN 1 tumor suppressor gene - type 2A: Medullary thyroid cancer, Pheochromocytoma, Parathyroid hyperplasia (MPP) - type 2B: Medullary thyroid cancer, Pheochromocytoma, Marfanoid habitus/Mucosal and intestinal neuromas (MMMP) - MEN 2A/2B: autosomal dominant; germline mutations involving RET proto-oncogene on chromosome 10

Question 836

Renal angiomyolipomas

Answer 836

Tuberous sclerosis

Question 837

Trimethoprim

Answer 837

- can cause hyperkalemia due to blockade of the epithelial sodium channel in the collecting tubule - TMP also competitevely inhibits renal tubular creatinine secretion and may cause an artificial increased in serum creatinine w/o affecting the GFR

Question 838

Single photon emission CT scan (SPECT)

Answer 838

- useful tool to evaluate for CAD and indicates inducible ischemia when a reversible defect is noted on stress and rest images - antiplatelet therapy is the preferred tx to prevent CAD in these pts

Question 839

Pleural effusion

Answer 839

-decrease in movement of ipsilateral chest wall, dullness to percussion, and DECREASED breath sounds

Question 840

consolidation of lung on auscultation

Answer 840

dullness to percussion, bronchial breath sounds (assuming patent airways), and egophony

Question 841

Clinical manifestations of infectious mononucleosis

Answer 841

- extreme fatigue, malaise, sore throat, fever, and generalized maculopapular rash - posterior cervical lymphadenopathy and palatal petechiae can be present - Splenomegaly is common - Heterophile antibodies are very sensitive and specific, but may be negative early in the illness; repeat testing may be helpful

Question 842

Pts w/ typical GERD symptoms require an upper GI endoscopy if they have alarm symptoms (dysphagia, odynophagia, weight loss, anemia, GI bleeding, or recurrent vomiting) or are men age > 50 w/ chronic (> 5 yrs) symptoms and cancer risk factors (eg tobacco use). All other pts can receive an empiric trial of PPI therapy and further evaluation if refractory to therapy

Answer 842

.

Question 843

Fresh frozen plasma is the therapeutic agent of choice for the coagulopathy in pts w/ liver failure

Answer 843

.

Question 844

Light's criteria

Answer 844

- used to classify pleural fluid as an exudate or transudate - must have at least one of the following to be conisdered an exudate: 1. pleural fluid protein/serum protein ratio > 0.5 2. pleural fluid LDH/serum LDH ratio > 0.6 3. pleural fluid LDH > 2/3 of the upper limit of normal for serum LDH - exudative pleural effusion, along w/ pleural fluid acidosis (pH

Question 845

Peptic ulcer disease (PUD)

Answer 845

- may present w/ epigastric pain, nausea, and/or early satiety in associated w/ food - symptoms of duodenal ulcer classically occur in the absence of a food buffer (eg 2-5 hrs after meals, on an empty stomach, or at night). - melena is a manifestation of upper GI bleeding, w/ PUD being one of the most common causes

Question 846

Vision development is critical during the first few years of life, and screening should occur at every well-child exam. Infants should be evaluated by observing fixation and tracking. The cover-uncover test should be performed in older infants and children to assess for strabismus. Visual acuity should begin at age 3 w/ the tumbling E or Snellen chart

Answer 846

.

Question 847

quadrivalent meningococcal vaccine

Answer 847

-should be give at age 11-12 followed by a booster dose at age 16 due to the risk of college outbreaks

Question 848

rotavirus vaccine

Answer 848

-given at age 2-8 months

Question 849

Abdominal US is the study of choice for diagnosis and follow-up of AAAs, as it has nearly 100% sensitivity and specificity for this condition

Answer 849

.

Question 850

Aminoglycosides

Answer 850

- abx used to treat serious gram-negative infections | - potentially nephrotoxic and drug levels and renal function must be monitored closely during therapy

Question 851

Most likely cause of UTI in pts w/ alkaline urine?

Answer 851

Proteus species - P. mirabilis secretes urease to alkalinize the urine (pH >7), leading to formation of struvite stones; the stone becomes a permanent source of bacteria to perpetuate the cycle; staghorn calculi - other urease producing bacteria: Morganella morganii, Pseudomonas species, Providencia species, Staph species, and Ureaplasma urealyticum

Question 852

pathogens most likely in acute onset prosthetic joint infection (

Answer 852

- Staph aureus - gram negative rods - anaerobes

Question 853

pathogens most likely responsible for prosthetic joint infection subacutely (> 3 months)?

Answer 853

- Coagulase negative staph - Propionibacterium species - Enterococci

Question 854

Parents cannot deny their children life-saving tx unless the benefits are minimal or would not alter the prognosis.

Answer 854

.

Question 855

Malaria

Answer 855

- should be suspected in any ill pt, especially those w/ a hx of FEBRILE PAROXYSMS, who have traveled to an endemic-tropical region. - THICK AND THIN BLOOD SMEARS should be ordered for parasite detection and quantification - Nonimmune children are at highest risk of death, but the sickle cell trait confers some protection from severe complications like cerebral malaria

Question 856

HIV infection should be suspected when an infant has failure to thrive, lymphadenopathy, and thrush in the setting of maternal IV drug abuse. Pregnant pts w/ risky behavior should undergo HIV antibody testing in the 1st AND 3rd trimesters (all women get HIV test in 1st trimester), as it can take up to 3 months to develop detectable antibody. Diagnosis is confirmed in infants up to 18 months by PCR TESTING

Answer 856

.

Question 857

Consider CMV as a late complication in post bone marrow transplant recipients who present w/ pneumonitis and colitis.

Answer 857

- typically develops in 45 days | - multifocal diffuse patchy infiltrates, upper and lower GI ulcers, arthralgias, myalgias, esophagitis

Question 858

Most common organ involved in graft-versus-host disease?

Answer 858

THE SKIN - skin rash is almost always seen - other organs commonly involved include the intestine, liver, and lung (bronchiolitis obliterans)

Question 859

Encapsulated bacteria, especially Strep pneumo, are the most common cause of pneumonia in HIV pts due to impaired humoral immunity

Answer 859

.

Question 860

Pneumocystis pneumonia

Answer 860

- dry cough and dyspnea | - CXR usually demonstrates bilateral diffuse infiltrates

Question 861

most common pathogen causing pneumonia in nursing home residents?

Answer 861

- Streptococcus pneumoniae | - also the most common cause of community-acquired pneumonia in adults

Question 862

Pts w/ cystic fibrosis suffer from life-threatening, recurrent sinopulmonary infections due to accumulation of viscous airway secretions. what are the most common organisms?

Answer 862

- Staph aureus is the most common cause of bacterial pneumonia in young children w/ CF!, esp. those w/ coexisting influenza infection - Pseudomonas is most common above the age of 20

Question 863

Pertussis

Answer 863

- should be suspected in an inadequately vaccinated pt w/ severe, paroxysmal cough, inspiratory whoop, or posttussive emesis - during the first month of illness, the diagnosis is confirmed by cultures and/or PCR of nasopharyngeal secretions - MACROLIDE ABX are the preferred tx of prevent spread of infection - will have LYMPHOCYTE-PREDOMINANT LEUKOCYTOSIS

Question 864

Right-sided endocarditis

Answer 864

- should be considered in pts w/ presumed hx of IV drug use - empiric abx tx of native-valve endocarditis should be geared toward methicillin-resistant Staph aureus, streptococci, and enterococci - Vancomycin is the most appropriate empiric abx

Question 865

Maternal combination antiretroviral therapy during pregnancy and neonatal zidovudine therapy can reduce perinatal HIV transmission to

Answer 865

- Zidovudine should be administered to the neonate for >6 wks - 3 drug regimine should be used for mother

Question 866

Elective C-section is beneficial if maternal HIV viral load is > 1,000 copies/mL, as it can reduce trasmission by 50%. Zidovudine plus C-section reduces the risk of transmission more than either intervention alone. However, combination antiviral therapy is more effective than any of these strategies in preventing neontal HIV infection.

Answer 866

.

Question 867

most common causes of acute bacterial rhinosinusitis?

Answer 867

- Strep pneumo - nontypeable H. flu - Moraxella catarrhalis - Due to increasing beta-lactamase resistance, the tx of choice is amoxicillin-clavulanic acid

Question 868

Entamoeba histolytica

Answer 868

- causative agent of amebiasis - found mostly in Southeast Asia, Africa, and central and south america - abdominal pain and bloody diarrhea

Question 869

Shigella

Answer 869

- common bacterial cause of acute diarrhea | - fever, abdominal pain, and bloody diarrhea

Question 870

Strongyloides stercoralis

Answer 870

- parasite found primarily in tropical and subtropical regions and can cause skin, GI, and pulmonary manifestations - N/V/ abdominal pain

Question 871

Cryptosporidium

Answer 871

- emerging and important cause of traveler's diarrhea | - consider in pts w/ persistent, nonbloody, watery diarrhea for > 2 wks

Question 872

in diabetic pts, the pathogenic mechanism of osteomyelitis adjacent to a foot ulcer is CONTIGUOUS SPREAD of infection

Answer 872

.

Question 873

C-section should be performed on women w/ active genital herpes lesions (primary or secondary) at the time of delivery to reduce the risk for neonatal HSV.

Answer 873

.

Question 874

HIV pts are at high risk for TB. A positive PPD test (skin induration of > 5 mm in HIV pts) requires prophylaxis w/ isoniazid (and pyridoxine) for 9 months.

Answer 874

.

Question 875

Alternatives to use of isoniazid and pyridoxine for 9 months as chemoprophylaxis in PPD positive individuals w/o active infection

Answer 875

- Pyrazinamide w/ Rifampin or Rifabutin for 2 months | - Rifampin alone for 4 months

Question 876

Sporotrichosis

Answer 876

- Gardener's disease - the initial lesion, a reddish nodule that later ulcerates, appears at the site of the thorn prick or other skin injury - from the site of inoculation, the fungus spreads along the lymphatics forming subcutaneous nodules and ulcers - adenopathy and systemic signs of infection are usually absent

Question 877

Meningococcal meningitis

Answer 877

- most common cause of bacterial meningitis in children and young adults - typically presents w/ fever, headache, neck stiffness, AMS, and a PETECHIAL OR PURPURIC RASH - prompt diagnosis and tx are critical given that it has a high morbidity and mortality rate even w/ appropriate tx

Question 878

Borrelia burgdorferi

Answer 878

- causes Lyme disease - usually acquired in late summer months after and Ixodes tick bite - rash (erythema chronicum migrans), headaches, fever, chills, and malaise

Question 879

Cytomegalovirus

Answer 879

-can cause infectious mononucleosis like illness, which presents w/ high fevers, fatigue, malaise, splenomegaly, and pharyngitis

Question 880

Haemophilus influenzae

Answer 880

-may cause meningitis, rhinorrhea, fever, epiglottitis, and ear infections

Question 881

Herpes simplex virus

Answer 881

-causes temporal lobe encephalitis in neonates and infants and typically presents w/ seizures

Question 882

Listeria monocytogenes

Answer 882

- transmitted vaginally, is 1 of the 3 most common causes of meningitis in newborns - also transmitted through unpasteurized milk or cheese from infected cows

Question 883

Erysipelas

Answer 883

- sudden onset of a sharply-demarcated, erythematous, edematous, tender skin lesion w/ raised borders in a febrile patient suggests erysipelas - most frequently implicated organism is group A beta-hemolytic streptococcus - specific type of cellulitis; inflammation of the superficial dermis - abrupt onset, and usually systemic signs, including fever and chills

Question 884

Clostridium perfringens

Answer 884

causative organism of gas gangrene

Question 885

All pts who are started on anti-tubercular therapy should also be started on vitamin supplements, especially pyridoxine (10 mg/day), to avoid peripheral neuropathy and other neurological complications. If the peripheral neuropathy has already developed, the dose of pyridoxine is increased to 100 mg/day. Hepatitis is another known side effect of isoniazid.

Answer 885

.

Question 886

Indications for transfusion of fresh frozen plasma?

Answer 886

- INR > 1.6: inherited deficiency of single clotting factors; prevent active bleeding in pt on anticoagulant therapy before a procedure; active bleeding - emergent reversal of warfarin: major or intracranial hemorrhage; prophylactic transfusion in a surgical procedure that cannot be delayed - acute DIC: w/ active bleeding and correction of underlying condition - microvascular bleeding during massive transfusion: > 1 blood volume (5L in adults) - replacement fluid for apheresis in thrombotic microangiopathies: TTP; HUS

Question 887

Indications for transfusion of platelets in adults

Answer 887

- 100,000 (rarely): surgery w/ active bleeding | - 100.4 or undergoing invasive procedure

Question 888

indications for transfusion of platelets in neonates

Answer 888

- 20,000: always transfuse - 20-30,000: consider transfusion; transfuse for clinical reasons (active bleeding, LP) - 30-50,000: transfuse if any of the following exist: - first week of life w/ birth weight

Question 889

Indications for transfusion of packed RBCs?

Answer 889

- acute sickle cell crisis to prevent stroke - acute blood loss > 1500mL (30% of blood volume) - symptomatic anemia (fatigue, weakness, dizziness, reduced exercise tolerance, SOB, changes in mental status, muscle cramps, angina, severe CHF) if they cannot function w/o treating the anemia - Hgb

Question 890

new onset pancytopenia almost always needs a bone marrow aspirate evaluation to help determine cause!

Answer 890

.

Question 891

name some CYP450 inducers

Answer 891

-carbamazepine, phenobarbital, phenytoin, rifampin

Question 892

name some CYP450 inhibitors

Answer 892

-phenothiazines, TCAs, cimetidine

Question 893

pain management in cancer pts

Answer 893

-follow WHO algorithm. Basically, start w/ non-opiods such as acetaminophen, NSAIDs, aspirin, COX inhibitors. If that doesn't work, then progress to weak opiods like vicodin, and possibly add non-opiods to regimen. Finally, progress to pure opioid regimen for sever pain. You can titrate pure opioids until pain relief, and you are only limited by patient side effects. From here you can switch to a different opiod due to low cross-tolerance between meds of this class.

Question 894

Central retinal VEIN occlusion

Answer 894

- blocks retinal vein, causing walls of vein to leak blood and excess fluid into retina. When fluid collects in the macula (area of retina responsible for central vision), vision becomes blurry. - "floaters" in your vision are another symptom from clotted blood in vitreous - in severe cases, the blocked vein causes painful pressure in the eye - commonly occurs w/ glaucoma, diabetes, age-related vascular disease, HTN, and blood disorders - no cure - look for DILATED TORTUOUS RETINAL VEINS ON EXAM

Question 895

Central retinal ARTERY occlusion

Answer 895

- ages 50-70 usually - most common medical problem associated with it is ARTERIOSCLEROSIS (carotid disease is found in 50%) - most common cause is THROMBOSIS, and less likely, embolus - first sign is SUDDEN and PAINLESS loss of vision that leaves you barely able to count fingers or determine light from dark - irreversible damage occurs after 90 minutes--> EMERGENCY - AFFERENT pupillary defect will be present - affected portion of retina (ischemic) will appear white and the foveal center (center of macula) appears red (cherry red spot)

Question 896

connection between pancreatitis and a blood lipid?

Answer 896

TRIGLYCERIDES - this is the 3rd most common cause of pancreatitis behind alcohol and gallstones - Tg >1000 (normal is

Question 897

Top causes of small bowel obstruction

Answer 897

- adhesions - malignancy - Crohn disease - hernias

Question 898

signs and symptoms of small bowel obstruction

Answer 898

- nausea - vomiting (associated w/ more proximal obstructions) - diarrhea (early finding) - constipation (late finding, as evidenced by the absence of flatus or bowel movements) - fever and tachycardia (occur late and may be associated w/ strangulation) - previous abdominal or pelvic surgery, inflammatory bowel disease, previous radiation therapy, may be part of the patient's medical hx - hx of malignancy (particularly ovarian and colonic)

Question 899

Remember that even if some children are not walking by age 12, it is usually OK, some may take until age 16-17 months.

Answer 899

.

Question 900

mechanism of action of ACE-inhibitors

Answer 900

- inhibit conversion of angiotensin-I to angiotensin-II - angiotensin-II is a potent vasoconstrictor and promotes production of aldosterone. Aldosterone promotes sodium and water retention. By inhibiting angiotensin-II production, ACE-i cause vasodilation and indirectly inhibit fluid volume increases that result from the actions of aldosterone

Question 901

most appropriate pharmacotherapy for pts w/ PCOS who want to conceive?

Answer 901

- Clomiphene citrate | - lifestyle modification such as diet and exercise also help

Question 902

Management of post-exposure prophylaxis to hepatitis B (HBsAg positive source)

Answer 902

- unvaccinated person who got exposed: hepatitis B vaccine series and hepatits B immune globulin - vaccinated person who got exposed: Only the hepatitis B vaccine booster! No need for HBIG if you already have circulating antibodies - if the source has an unknown HBsAg status, then administer hep B vaccine in unvaccinated person; no treatment for those already vaccinated

Question 903

at what gestational age are steroids (Betamethasone) indicated in preterm birth?

Answer 903

23 - 34 weeks | -before 23 weeks the fetus is unable to benefit, and after 34 weeks the lungs are already developed

Question 904

name some tocolytics

Answer 904

- terbutaline - magnesium sulfate - nifedipine - indomethacin

Question 905

definition of preterm labor

Answer 905

occurring before 37 weeks

Question 906

normal pregnancy length

Answer 906

37 - 42 weeks | -measured from first day of last menstrual period

Question 907

cervical cerclage

Answer 907

- placement of stitches in cervix to hold it closed | - used to keep a weak cervix from opening early

Question 908

most common causes of pneumonia from birth to 3 wks?

Answer 908

viral: CMV, rubella, HSV bacterial: GBS, Listeria, E. coli

Question 909

most common causes of pneumonia from 3 wks to 3 months?

Answer 909

- viral: RSV, Parainfluenza virus, Influenza virus, Adenovirus - bacterial: S. pneumo, Chlamydia trachomatic, Bordetella pertussis

Question 910

most common causes of pneumonia from 4 months to 5 years?

Answer 910

- viral: RSV, parainfluenza virus, adenovirus, human metapnuemovirus, influenza type A - bacterial: S. pneumo, Chlamydia pneumoniae, Mycoplasma pneumoniae

Question 911

most common causes of pneumonia from 5 years to 18 years

Answer 911

- viral: adenovirus, EBV, parainfluenza, influenza, rhinovirus - bacterial: S. pneumo, S. aureus, Atypical pneumonia (Mycoplasma, Chlamydia)

Question 912

most common causes of pneumonia from 18 years to 65 years (no comorbidity)?

Answer 912

- viral: parainfluenza virus, adenovirus, influenza virus | - bacterial: S. pneumo, atypical pneumonia (Mycoplasma, Chlamydia)

Question 913

most common causes of pneumonia over 65 years (no comorbidity)

Answer 913

- viral - bacterial: S. pneumo, respiratory viruses, Haemophilus influenzae, gram negative bacilli, S. aureus (moraxella and Legionella are less common)

Question 914

most common causes of pneumonia in smokers?

Answer 914

- S. pneumo - Haemophilus influenzae - Moraxella catarrhalis - Legionella pneumonia

Question 915

most common causes of pneumonia in alcoholics?

Answer 915

- S. pneumo - Anaerobes - Klebsiella

Question 916

most common cause of pneumonia in IV drug users?

Answer 916

S. aureus

Question 917

most common causes of pneumonia in CF?

Answer 917

- early disease: S. aureus | - late disease: Pseudomonas aeruginosa

Question 918

most common causes of pneumonia from animal exposure?

Answer 918

- birds: Psittacosis - rabbits: tularemia - livestock or cats: Coxiella burnetii

Question 919

number one cause of kidney stones?

Answer 919

Hyperparathyroidism! | -everyone must be tested for parathyroid gland malignancy or problem

Question 920

Type of transfusion reaction in pts w/ IgA deficiency if given blood with IgA in it?

Answer 920

ANAPHYLACTIC

Question 921

Acute hemolytic transfusion reaction

Answer 921

- type 2 hypersensitivity reaction - Intravascular hemolysis (ABO blood group incompatibility) or extravascular hemolysis (host antibody reaction against foreign antigen on donor RBCs) - fever, hypotension, tachypnea, tachycardia, flank pain, hemoglobinemia (intravascular), jaundice (extravascular)

Question 922

allergic nonhemolytic transfusion reaction

Answer 922

- type 1 hypersensitivity reaction against plasma proteins in transfused blood - urticaria, pruritis, wheezing, fever - treat with antihistamines

Question 923

Anaphylactic transfusion reaction

Answer 923

- severe allergic reaction - IgA deficient individuals must receive blood products that lack IgA - Dyspnea, bronchospasm, hypotension, respiratory arrest, shock

Question 924

Febrile nonhemolytic transfusion reaction

Answer 924

- type 2 hypersensitivity raction - host antibodies against donor HLA antigens and leukocytes - fever, headaches, chills, flushing

Question 925

delayed hemolytic transfusion reaction

Answer 925

- can occur 1-4 wks after transfusion - usually extravascular hemolysis - mild symptoms; unexplained fatigue, jaundice, fever - direct coombs positive

Question 926

initial management of acute aortic dissection?

Answer 926

Beta blockers! Then possible nitroprusside, followed by surgical correction if indicated

Question 927

which 3 disorders have a common presentation in the elderly

Answer 927

-hypothyroidism, depression, anemia

Question 928

what lab value is frequently increased in non-hodgkin's lymphoma?

Answer 928

serum LDH

Question 929

antihypertensives during pregnancy

Answer 929

- methyldopa - labetalol - nifedipine

Question 930

antihypertensive for severe preeclampsia

Answer 930

Hydralazine

Question 931

erysipelas

Answer 931

- sudden onset of a sharply-demarcated, erythematous, edematous, tender skin lesion w/ raised borders in a febrile patient - group A beta-hemolytic strep most frequent

Question 932

All pts started on isoniazid should also be started on pyridoxine (vitamin B6) 10 mg/day. If peripheral neuropathy has already developed, increase dose to 100 mg/day.

Answer 932

.

Question 933

Neurocysticercosis

Answer 933

- most common parasitic infection of the brain | - most prevalent in rural areas w/ poorer sanitary conditions and where pigs are raised

Question 934

prion diseases

Answer 934

- Creutzfeldt-Jacob disease and Kuru - spongiform encephalopathy - intracytoplasmic vacuoles diffusely throughout gray matter on microscopy

Question 935

Hydatid cysts

Answer 935

- caused by Echinococcus species - usually seen in the liver and lungs - more common in SHEEP BREEDERS

Question 936

Bacillary angiomatosis

Answer 936

- bright red, firm, friable, exophytic nodules in an HIV infected patient usually - caused by Bartonella, a gram negative bacillus - oral erythromycin is tx

Question 937

Molluscum contagiosum

Answer 937

- caused by poxvirus | - centrally-umbilicated, dome-shaped papules that are non-pruritic

Question 938

Kaposi sarcoma

Answer 938

- usually on trunk, face, and extremities - papules that become plaques or nodules - color changes from light brown, to pink, to dark violet

Question 939

HIV infected individuals w/ CD4 count > 200/uL should receive all routine vaccinations for adults, as well as serial pneumococcal boosters. Men who have sex w/ men should also get hepatitis A vaccine. Pts w/ CD4 count

Answer 939

.

Question 940

Acute HIV infection

Answer 940

- can present w/ a mononucleosis-like syndrome consisting of fever, night sweats, lymphadenopathy, arthralgias, and diarrhea - making the diagnosis at an early stage can be beneficial both to the individual patient and from a public health standpoint

Question 941

In HIV infected pts, diarrhea can be due to a variety of organisms (Salmonella, shigella, campylobacter, C. diff, Giardia, Cryptosporidium, Mycobacterium avium, CMV). Therefore, an attempt should be made to identify the causal organism prior to instituting therapy so that an appropriate antibiotic may be chosen (stool culture, exam for ova and parasites, etc.)

Answer 941

.

Question 942

Echinococcus granulosus

Answer 942

- in humans, hepatic hydatid cysts are due to infection by this organism - dogs are the definitive host - a cystic hepatic lesion w/ eggshell calcification is highly suggestive of infection w/ this organism - may or may not be a hx of sheep breeding - surgical resection under cover of albendazole

Question 943

Pneumocystis jirovecii pneumonia

Answer 943

-common opportunistic infection in AIDS pts w/ CD4 35 to minimize pulmonary complications!

Question 944

Risk factors for C. diff

Answer 944

- recent hospitalization, advanced age, or antibiotic use (most commonly fluoroquinolones, penicillins, cephalosporins, and clindamycin) - C. diff colitis can range from mild colitis (watery diarrhea, low-grade fever, abdominal pain, and leukocytosis) to fulminant colitis w/ toxic megacolon - diagnosis is usually confirmed w/ stool studies for C. diff toxin (PCR or enzyme immunoassay)

Question 945

tx for C. diff colitis

Answer 945

Metronidazole or ORAL vancomycin

Question 946

Unexplained leukocytosis in hospitalized pts should raise suspicion for C. difficile, even without diarrhea

Answer 946

.

Question 947

Coccidiodomycosis

Answer 947

- endemic in southwestern U.S., as well as Central and South America - primary pulmonary infection: fever, fatigue, dry cough, weight loss, pleuritic chest pain - cutaneous findings: erythema multiforme, erythema nodosum, arthralgias

Question 948

Histoplasmosis

Answer 948

- southeastern, mid-atlantic, and central U.S. | - acute pneumonia; cough, fever, and malaise

Question 949

Blastomycosis

Answer 949

- south-central and north-central U.S. - affects lungs, skin, bones, joints, and prostate - infection in immunocompetent hosts is uncommon - primary pulmonary infection is asymptomatic or presents w/ flu-like symptoms

Question 950

Invasive aspergillosis

Answer 950

- immunocompromised pts (those w/ neutropenia, taking cytotoxic drugs such as cyclosporine, high doses of steroids) - fever, cough, dyspnea, or hemoptysis - CXR may show cavitary lesions - CT: pulmonary nodules w/ THE HALO SIGN or lesions w/ an AIR CRESCENT

Question 951

Cryptococcus

Answer 951

-meningoencephalitis in HIV pts whose CD4 count is

Question 952

Tx for cryptococcus

Answer 952

initial: Amphotericin B w/ flucytosine maintenance: fluconazole

Question 953

Pts w/ HIV who have subacute-onset of low-grade fever, headache, and signs of increased ICP should be evaluated for cryptococcal meningitis. Diagnosis is established by detection of the cryptococcal antigen or isolation of the organism in CSF.

Answer 953

.

Question 954

Malignant otitis externa

Answer 954

- ear discharge and severe ear pain that worsens despite the use of topical antibiotics - pain often radiates to TMJ - presence of granulation tissue in the external auditory meatus - DM and immunosuppressive conditions are important risk factors - Pseudomonas aeruginosa most frequently!

Question 955

Acute bacterial parotitis

Answer 955

- presents w/ painful swelling of the parotid gland that is aggravated by chewing - high fever and a tender, swollen, and erythematous parotid gland are common - this post-op complications can be prevented w/ adequate fluid hydration and oral hygiene - most common infectious agent is Staph aureus!

Question 956

Fluoroquinolone use is associated w/ what complication?

Answer 956

- Tendinopathy and tendon rupture (Achilles most common) - Pts can develop tendon pain within 24 hrs w/ a median of 8 days after starting the drug - Pts should stop the drug at onset of symptoms, avoid exercise and/or use of the affected area, and seek medical care for symptom evaluation and changing to a non-fluoroquinolone antibiotic

Question 957

Causes of diarrhea in HIV pts

Answer 957

- non-opportunistic infections: Salmonella, campylobacter, entamoeba, chlamydia, shigella, giardia - opportunistic infections: CMV, cryptosporidium, isopora belli, blastocystis, MAC, Herpes simplex virus, adenovirus, HIV itself - non-infectious: Kaposi sarcoma, lymphoma of GI tract - Hematochezia and lower abdominal cramps are usually due to colonic infection w/ CMV, C. diff, Shigella, Entamoeba, or campylobacter

Question 958

CMV colitis

Answer 958

- suspect in HIV positive pt w/ bloody diarrhea and a normal stool exam; they should have a colonoscopy w/ biopsy - bloody diarrhea w/ abdominal pain - colonoscopy shows multiple ulcers and mucosal erosions - biopsy demonstrates large cells w/ eosinophilic intranuclear and basophilic intracytoplasmic inclusions (owl's eye effect) - tx is GANCICLOVIR; Foscarnet is used in cases of ganciclovir failure

Question 959

Entamoeba histolytica

Answer 959

- parasite that cause bloody diarrhea, but can usually be diagnosed by visualization of trophozoites on stool exam - colonoscopy shows presence of "flask-shaped" colonic ulcers

Question 960

TMP/SMX is used in HIV pts to prevent what?

Answer 960

- Pneumocystis jirovecii | - Toxoplasma gondii

Question 961

Azithromycin is recommended for prophylaxis of Mycobacterium Avium complex in HIV + pts w/ CD4

Answer 961

.

Question 962

Fluconazole is used for prophylaxis against Cryptococcus and Coccidioides in HIV + pts who have had these diseases in the past. Also used w/ frequent Candida infections.

Answer 962

.

Question 963

Infectious mononucleosis

Answer 963

- most commonly caused by EBV - presents w/ fever, fatigue, exudative pharyngitis, and diffuse cervical lymphadenopathy - a polymorphous, maculopapular rash frequently develops after administration of amoxicillin! - pts should avoid sports for 3 or more wks due to risk of splenic rupture

Question 964

Adenoviruses

Answer 964

- frequent causes of URI; coryza, pharyngitis, tonsillitis, conjunctivitis - fever, malaise, headache, and abdominal pain

Question 965

Coxsackie virus

Answer 965

-cause hand-foot-mouth disease and herpangina (vesicles on hard palate)

Question 966

CMV is a less common cause of infectious mononucleosis and tends to have a milder presentation

Answer 966

.

Question 967

Hepatitis A vaccine

Answer 967

- chronic liver disease (including HBV and HCV) - men who have sex with men - IV drug users

Question 968

Hepatitis B vaccine

Answer 968

-all pts w/o documented immunity to HBV

Question 969

HPV vaccine

Answer 969

-men and women age 9-26

Question 970

Influenza vaccine

Answer 970

-annually for all pts

Question 971

Meningococcus vaccine

Answer 971

- all pts age 11-18 - large groups living in close proximity (college students, military recruits, incarcerated pts) - asplenia or complement deficiency

Question 972

Pneumococcus vaccine

Answer 972

- PCV13 once | - PPSV23 8 weeks later, then every 5 years

Question 973

Tetanus, diptheria & pertussis vaccine

Answer 973

- Tdap once - repeat Tdap for women during each pregnancy - Td every 10 years following Tdap

Question 974

In addition to the vaccines recommended for the general population, pts w/ HIV infection should receive pneumococcal vaccination. Most pts w/ HIV should also receive vaccination for hepatits A and B if they do not have documented evidence of immunity to these viruses. Live vaccines are generally contraindicated.

Answer 974

.

Question 975

Invasive aspergillosis

Answer 975

- occurs in immunocompromised pts, who may present w/ fever, cough, dyspnea, or hemoptysis - CXR may show a cavitary lesion, and CT scan shows pulmonary nodules w/ a halo sign or lesions w/ an air crescent

Question 976

Postexposure HIV prophylaxis w/ 3 drug antiretroviral therapy for 4 weeks is recommended following high-risk occupational exposure to blood or body fluids from an HIV infected individual. Therapy should be started as soon as possible, preferably in the first few hours. Try Tenofovir-Emtricitabine with raltegravir.

Answer 976

.

Question 977

Mumps

Answer 977

- can cause parotitis and orchitis - most common in postpubertal young men, ages 15-29 - infertility is a rare complication - tx is supportive w/ application of cold compresses to parotid area or testes - most common complications are aseptic meningitis and encephalitis

Question 978

Pneumocystis pneumonia (PCP)

Answer 978

-likely in pts w/ HIV who have a nonproductive cough, exertional dyspnea, fever, severe hypoxia, bilateral interstitial infiltrates on CXR, and a normal white count, especially if their CD4 35 on room air

Question 979

Retropharyngeal abscess

Answer 979

-should be suspected in children who present w/ fever, dysphagia, inability to extend the neck, muffled voice, and lateral x-ray showing a widened prevertebral space

Question 980

common complications of supracondylar fracture of humerus

Answer 980

- brachial artery injury (most common) - median nerve injury (most common) - cubitus varus deformity - compartment syndrome/Volkmann ischemic contracture

Question 981

supracondylar fractures of humerus

Answer 981

- associated w/ a high risk of neurovascular injury - radial and brachial pulses must be assessed before and after reduction as the brachial artery can be impinged - motor and sensory function should also be assessed due to risk of median nerve injury

Question 982

neonatal chlamydial conjunctivitis

Answer 982

- typically occurs at 5-14 days of life and presents w/ eyelid swelling, chemosis, and watery or mucopurulent discharge - blood-stained eye discharge is highly characteristic of chlamydial conjunctivitis - first line tx is oral erythromycin

Question 983

tx of choice for infants w/ gonococcal conjunctivitis (aka ophthalmia neonatorum)

Answer 983

- IV or IM ceftriaxone or cefotaxime - ceftriaxone should be avoided in infants w/ hyperbilirubinemia as it results in displacement of bilirubin from albumin-binding sites, increasing the risk of kernicterus

Question 984

prophylaxis against gonococcoal conjunctivitis in neonate?

Answer 984

-topical erythromycin (note that once it has occured, it is treated w/ IM or IV ceftriaxone/cefotaxime)

Question 985

Application of topical silver nitrate is used for routine neonatal ophthalmic prophylaxis in some countries, and unlike topical erythromycin ointment, is effective prophylaxis against penicillinase-producing strains of Neisseria gonorrhoeae. Topical silver nitrate is not available in US given an increased risk of chemical conjunctivitis w/ its use.

Answer 985

.

Question 986

Legg-Calve-Perthes disease (idiopathic avascular necrosis of the femoral capital epiphysis)

Answer 986

-unilateral subacute hip pain in a male child coupled w/ a progressive antalgic gait, thigh muscle atrophy, decreased hip range of motion, and collapse of the ipsilateral femoral head on plain pelvic x-rays

Question 987

Slipped capital femoral epiphysis (SCFE)

Answer 987

- the metaphysis and proximal femur slip relative to the epiphysis at the epiphyseal plate - the capital femoral epiphysis remains structurally intact within the acetabulum - classic presentation is obese adolescent w/ complainst of pain

Question 988

Most common etiology of osteomyelitis in pediatrics?

Answer 988

-S. aureus due to hematogenous seeding to the metaphysis

Question 989

Duchenne muscular dystrophy

Answer 989

- most common childhood myopathy | - causes proximal muscle weakness and calf pseudohypertrophy

Question 990

Osteosarcoma

Answer 990

- primary bone cancer that produces Codman's triangle in the metaphysis of long bones - note that Ewing sarcoma tends to affect the diaphysis of long bones

Question 991

false labor

Answer 991

- progressive cervical changes are absent! - contractions are usually irregular and discomfort is readily relieved by sedation! - all such pts need reassurance only

Question 992

true labor

Answer 992

- contractions that occur at regular intervals w/ a progressively shortening interval and increasing intensity - pain is in the back and upper abdomen and is NOT relieved by sedation - cervical changes are typically observed

Question 993

Retinoblastoma

Answer 993

- every case of leukocoria is considered retinoblastoma, until proven otherwise!!! such cases should be promptly referred to an ophthalmologist - inactivation of the Rb suppressor gene, may be familial or sporadic - highly malignant - other manifestations: strabismus, decreased vision, ocular inflammation, eye pain, glaucoma, orbital cellulits - mass w/ calcifications on US or CT is highly suggestive

Question 994

initial tx of strabismus in children

Answer 994

-covering the normal eye

Question 995

Hereditary spherocytosis

Answer 995

- autosomal dominant - should be suspected in a patient w/ persistent jaundice, hemolytic anemia, splenomegaly, positive family hx, and spherocytes on peripheral blood smear - RBC fragility on acidified glycerol lysis and eosin-5-maleimide binding tests confirm the diagnosis - mutation in ankyrin gene causes deficiency in SPECTRIN - increased mean corpuscular hemoglobin concentration

Question 996

hereditary spherocytosis

Answer 996

- autosomal dominant, northern european - hemolytic anemia, jaundice, splenomegaly - increased MCH concentration, spherocytes, negative coombs test, increased osmotic fragility on acidified glycerol lysis test, abnormal eosin-5-maleimide binding test - tx: folic acid, blood transfusions, splenomegaly - complications: pigment gallstones, aplastic crises from parvovirus B19 infection

Question 997

pharmacologic tx for Alzheimer's dementia

Answer 997

- cholinesterase inhibitors (donepezil, galantamine, rivastigmine) effective in mild to moderate dementia; may improve quality of life, cognitive functions, memory, language, thought, and reasoning; they slow the cognitive decline - Donepezil is approved for all stages of Alzheimer's dementia - Memantine, an N-methyl-D-aspartate receptor antagonist, is approved for moderate to severe dementia

Question 998

moving from supine to sitting can increase the functional residual capacity (FRC) by 20-35%. In normal adults, this can amount to several hundred cubic centimeters of lung volume. Increasing FRC can help prevent post-op atelectasis.

Answer 998

.

Question 999

Laparoscopy w/ visualization and biopsy of implants is the only definitive way to diagnose endometriosis. It is indicated when NSAIDs and hormonal contraceptives have failed.

Answer 999

.

Question 1000

Pts w/ endometriosis

Answer 1000

- increased risk of impaired fertility or infertility due to chronic inflammation and adhesion formation - endometriosis is diagnosed in 25-50% of women being evaluated for infertility, and almost half of women w/ endometriosis have impaired fertility

Question 1001

risk factors for abruptio placenta

Answer 1001

-advanced age, HTN, preeclampsia, renal disease, cocaine or tobacco use

Question 1002

risk factors for breast cancer

Answer 1002

-positive family hx, genetic mutations (BRCA1, BRCA2, p53), early menarche, late menopause, prolonged hormone replacement therapy, and nulliparity

Question 1003

risk factors for endometrial carcinoma

Answer 1003

-advancing age, unopposed estrogen or prolonged use of TAMOXIFEN, obesity, nulliparity, and anovulatory conditions (PCOS)

Question 1004

Higher rates of ovarian cancer in pts w/ endometriosis

Answer 1004

.

Question 1005

Pts who have experienced 2 episodes of acute mania should be considered for long-term (years), if not lifetime, maintenance tx w/ lithium, esp. if the episodes were severe or there is a family hx. Pts w/ a hx of 3 or more relapses are recommended to have lifetime maintenance therapy.

Answer 1005

.

Question 1006

Enterobius vermicularis

Answer 1006

- aka pinworms - highly contagious and manifests as nocturnal perianal pruritus - albendazole and pyrantel pamoate (for pregnant pts!) are first-line tx options - diagnosed by scotch tape test

Question 1007

Trypanosoma cruzi

Answer 1007

- aka Chagas disease - primarily affects the heart (cardiomyopathy, right bundle branch block) and GI tract (megacolon, megaesophagus) - Benznidazole is first-line anti-trypanosomal tx!

Question 1008

Strongyloidiasis

Answer 1008

- urticaria, abdominal pain, respiratory symptoms (eg dry cough, dyspnea, wheezing) - tx w/ IVERMECTIN

Question 1009

Onchocerciasis

Answer 1009

- aka river blindness - causes ocular lesions and dermatitis - tx w/ ivermectin

Question 1010

Metronidazole

Answer 1010

-used for protozoan infections such as amebiasis (acute dysentery, liver abscess) and trichomonas vaginitis (green-yellow, frothy, malodorous discharge) as well as anaerobic intra-abdominal infections (diverticulitis, peritonitis, cholangitis, abscess)

Question 1011

Ankylosing spondylitis

Answer 1011

- seronegative spondyloarthropathy that presents w/ progressive inflammatory back pain and stiffness - in the setting of suggestive findings on history and physical, AS is confirmed by plain film x-ray demonstrating fused sacroiliac joints and/or bamboo spine - presents in second or third decade of life usually; male:female ratio 2:1 - progressive low back pain and spinal stiffness of > 3 months duration usually - morning stiffness > 30 min and back pain improves w/ exercise - decreased lumbar spinal mobility and tenderness over SI joints is common - AP x-ray of SI joints; fusion of SI joints and/or bamboo spine is diagnostic

Question 1012

Serum BUN and creatinine are usually DECREASED in pregnant pts due to an INCREASE in renal plasma flow and GFR.

Answer 1012

.

Question 1013

Teenagers w/ serious suicidal ideation must be hospitalized and their parents informed of the situation.

Answer 1013

.

Question 1014

Long-term supplemental oxygen therapy has been proven to prolong survival in pts w/ COPD and hypoxemia. Criteria for therapy?

Answer 1014

- PaO2 55%) | - evidence of cor pulmonale

Question 1015

opioid withdrawl

Answer 1015

- symptoms: nausea, vomiting, cramps, diarrhea, dysphoria, restlessness, rhinorrhea, lacrimation, myalgias, arthralgias - physical exam: mydriasis, piloerection, hyperactive bowel sounds - oral or IM methadone is the tx of choice

Question 1016

Guillain-Barre Syndrome

Answer 1016

- 2/3 have an antecedent respiratory or GI infection - Campylobacter jejuni is most common precipitant; others include human herpes virus, Mycoplasma, H. influenza - more common in pts w/ lymphoma, sarcoidosis, and SLE - Recent HIV infection and immunization have also been associated

Question 1017

Screening for secondary causes of HTN should be done when?

Answer 1017

-in pts who have resistant HTN (requiring > 3 meds from different classes) and in young (

Question 1018

Counseling for nonpharmacologic therapy (lifestyle modification) should be part of the overall management of HTN at every office visit. All pts should be encouraged to restrict dietary salt intake; have a diet rich in fruit, vegetables, and low-fat dairy products; engage in regular aerobic exercise; lose weight; and limit alcohol intake.

Answer 1018

.

Question 1019

Pts w/ Huntington's chorea

Answer 1019

- usually present in 40s or 50s w/ chorea and/or behavioral disturbance - atrophy of the CAUDATE nucleus is a characteristic feature.

Question 1020

diffuse atrophy of the cerebral cortex

Answer 1020

Alzheimer's disease

Question 1021

atrophy of the lenticular nucleus

Answer 1021

Wilson's disease

Question 1022

atrophy of the frontal and/or temporal lobes

Answer 1022

Pick's disease

Question 1023

carbon monoxide poisoning

Answer 1023

- most important factor is the history, because physical symptoms can be vauge - suspect in cases of smoke inhalation and when multiple people from the same confined quarters present w/ headache, nausea, and abdominal discomfort - pinkish-red skin hue is noted on exam and diagnosis is confirmed by carboxyhemoglobin levels

Question 1024

characteristic of inhaled cyanide

Answer 1024

-bitter almond breath

Question 1025

sudden-onset respiratory distress in a toddler w/ focal findings on physical exam

Answer 1025

- foreign body aspiration - CXR is of limited help as most objects are radiolucent - a hx of choking, if witnessed, is very helpful in diagnosis - immediate bronchoscopy is indicated to remove the foreign body

Question 1026

tx for croup?

Answer 1026

-nebulized racemic epinephrine

Question 1027

interstitial nephritis

Answer 1027

- 70% of cases are caused by drugs such as cephalosporins, penicillins, sulfonamides, sulfonamide containing diuretics, NSAIDs, rifampin, phenytoin, and allopurinol - discontinuing the offending agent is the tx of drug-induced interstitial nephritis - clinical features include fever, rash, and arthralgias - peripheral eosinophilia, hematuria, sterile pyuria, eosinophiluria, and WBC casts

Question 1028

Diabetic nephropathy

Answer 1028

- characterized by proteinuria and a progressive decline in GFR - hallmark is nodular glomerulosclerosis (w/ Kimmelstiel-Wilson nodules) but diffuse glomerulosclerosis is more common - progression can be slowed w/ strict glycemic control, tx of HTN, and angiotensin axis blockade

Question 1029

most common adverse effect of inhaled corticosteroid therapy?

Answer 1029

-oropharyngeal thrush (oral candidiasis)

Question 1030

PCOS

Answer 1030

- diagnostic: 2 of 3 of the following: androgen excess, oligo- or anovulation, polycystic ovaries on US; AND exculsion of other hyperandrogenic conditions - tx: weight loss; combined hormonal contraceptives for hyperandrogenism and menstrual dysfunction; Clomiphene citrate for ovulation induction; metformin for coexisting type 2 DM - comorbidities: overweight/obesity,glucose intolerance/DM, dyslipidemia, OSA, endometrial hyperplasia/cancer

Question 1031

first-line tx for ovulation induction in PCOS

Answer 1031

clomiphene citrate

Question 1032

absolute contraindications to combined hormonal contraceptives

Answer 1032

-migraine w/ aura -> 15 cigarettes/day and age > 35 -stage 2 HTN (> 160/100) -Hx of venous thromboembolic disease -Hx of stroke or ischemic heart disease -breast cancer -cirrhosis and liver cancer -major surgery w/ prolonged immobilization -

Question 1033

Always suspect MS in a female w/ multiple neurologic presentations that are interspaced between time periods. Optic neuritis can result in blurring of vision, and is often associated w/ retrobulbar pain.

Answer 1033

.

Question 1034

Myasthenia gravis

Answer 1034

- weakness in the proximal limb and torso muscles; ocular muscles may or may not be involved - diplopia, ptosis, facial weakness, and dysphagia - 10-15% also have a thymoma - ocular involvement is painless - antibodies against post-synaptic Ach receptor

Question 1035

most common primary tumors that metastasize to liver?

Answer 1035

-GI tract, lung, breast

Question 1036

alpha-fetoprotein

Answer 1036

-can be used in diagnosis of hepatocellular carcinoma

Question 1037

Drug induced interstitial nephritis

Answer 1037

- usually caused by cephalosporins, penicillins, sulfonamides, NSAIDs, rifampin, phenytoin, and allopurinol - pts present w/ arthralgias, rash, renal failure and the UA will show WBC casts and eosinophiluria

Question 1038

Vitiligo

Answer 1038

- autoimmune condition characterized by areas of depigmentation completely lacking melanocytes - sometimes associated w/ other autoimmune conditions such as pernicious anemia, autoimmune thyroid disease, type 1 DM, primary adrenal insufficiency, hypopituitarism, and alopecia areata

Question 1039

Alveolar hypoventilation w/ CO2 retention can lead to respiratory acidosis along w/ CO2 narcosis. Acute kidney injury can cause a non-anion gap metabolic acidosis due to impaired acid excretion or an anion gap acidosis due to retention of unmeasured uremic toxins.

Answer 1039

.

Question 1040

TCAs are the drugs of choice for diabetic neuropathy. They can worsen urinary symptoms (due to cystopathy) and orthostatic hypotension (due to CV autonomic neuropathy). Gabapentin is an alternative for these pts.

Answer 1040

.

Question 1041

HIV associated Kaposi sarcoma

Answer 1041

- AIDS defining malignancy due to human herpesvirus 8 - cutaneous KS develops most commonly on the lower extremities, face, oral mucosa, and genitalia - the lesions usually appear as multiple violaceous papules - diagnosis is made clinically, but may require biopsy

Question 1042

Condyloma acuminata (anogenital warts)

Answer 1042

- due to human papillomavirus - pts develop skin-colored, whitish, or grayish verrucous and filiform papules in the anal/perianal area (more often in men), penile shaft, or vulvovaginal and cervical areas

Question 1043

Leukocytoclastic vasculitis

Answer 1043

- can be due to infections, medications, inflammatory conditions, or malignancy - typically presents as non-blanching, 1-3 mm violaceous papules that can cluster/coalesce into plaques - older lesions appear brownish-red; newer ones are more violaceous

Question 1044

Neurofibromatosis type 1 typically presents w/ widespread subcutaneous nodules associated w/ multiple cafe-au lait spots. Neurofibromatosis type 2 can present w/ a vestibular schwannoma and raised plaque-like lesions or subcutaneous nodules (from nerve swelling)

Answer 1044

.

Question 1045

Necrotizing enterocolitis

Answer 1045

- should be suspected in a newborn w/ feeding intolerance, abdominal distension, and bloody stools - risk factors: prematurity, hypotension, congenital heart disease - hallmark x-ray finding is PNEUMATOSIS INTESTINALIS - can result in strictures, short bowel syndrome, or death

Question 1046

Craniopharyngiomas

Answer 1046

-benign suprasellar tumors that present w/ visual defects, headache, and symptoms of pituitary hormonal deficiency

Question 1047

Open-angle glaucoma

Answer 1047

-causes GRADUAL loss of peripheral vision in both eyes, leading to tunnel vision

Question 1048

optic neuritis

Answer 1048

- inflammatory demyelinating disease usually associated with MS - pts typically develop acute or subacute PAINFUL vision loss w/ ABNORMAL PUPILLARY RESPONSE to light in the affected eye

Question 1049

Pseudotumor cerebri

Answer 1049

-most common in obese women age

Question 1050

alpha-1 antitrypsin deficiency

Answer 1050

-suspect in non-smoking adults

Question 1051

pulmonary function testing in emphysema

Answer 1051

- decreased FEV1/FVC ratio - increased TLC - Decreased DLCO

Question 1052

most important causes of thyrotoxicosis with low radioactive iodine uptake?

Answer 1052

1. subacute painless thyroiditis 2. subacute granulomatous (De Quervain's; painful) thyroiditis 3. iodine-induced thyroid toxicosis 4. levothyroxine overdose 5. struma ovarii

Question 1053

Struma ovarii

Answer 1053

-ovarian teratoma which produces thyroid hormones, thereby causing thyrotoxicosis

Question 1054

Pseudotumor cerebri

Answer 1054

- suspect in young obese female w/ a headache that is suggestive of a brain tumor, but w/ normal neuroimaging and elevated CSF pressure - papilledema, visual field defects, 6th nerve palsy - glucocorticoids, vitamin A, and OCPs can provoke - impaired absorption of CSF by arachnoid villi - tx: weight reduction and acetazolamide; possibly shunting or optic nerve sheath fenestration to prevent blindness

Question 1055

Creutzfeldt-Jakob disease

Answer 1055

- should be suspected in an older adult patient (between 50-70) w/ rapidly progressive dementia, myoclonus, sharp wave complexes on EEG, and/or elevated 14-3-3 proteins in CSF - a rapidly progressive course and prominent myoclonus differentiate CJD from other causes of dementia - can also test for PRNP gene

Question 1056

most prevalent antibodies in pts w/ Hashimoto's thyroiditis?

Answer 1056

-anti-TPO

Question 1057

anti-mitochondrial antibodies

Answer 1057

-primary biliary cirrhosis (bear holding a mitochondria)

Question 1058

Ventricular aneurysm

Answer 1058

- occurs as a late complication of acute ST segment elevation or transmural myocardial infarction - ECG shows persistent ST segment elevation along w/ deep Q waves in the same leads - progressive left ventricular enlargement causing heart failure may occur in addition to refractory angina, ventricular arrhythmias, or mural thrombus - echo is diagnostic

Question 1059

extension of aortic dissection frequently involves the right coronary artery and results in acute inferior MI w/ ST-segment elevation in leads II, III, and aVF

Answer 1059

.

Question 1060

papillary muscle rupture

Answer 1060

- complication of acute MI that typically occurs 2-7 days after infarct - acute severe mitral regurgitation leading to hypotension and pulmonary edema

Question 1061

Tamoxifen

Answer 1061

- mixed agonist and antagonist activity on estrogen receptors - estrogenic effects of tamoxifen increase the risk of endometrial cancer and venous thrombosis

Question 1062

pulmonary contusion

Answer 1062

- not uncommon after high-speed car accidents | - symptoms usually develop in the first 24 hrs and a patchy alveolar infiltrate on CXR is typical

Question 1063

Note that although IV ceftriaxone is effective in treating early localized Lyme disease, it is reserved for early disseminated and late disease as oral doxycycline is very effective in resolving early localized disease.

Answer 1063

.

Question 1064

tx for lyme disease in children

Answer 1064

amoxicillin (doxycycline can cause tooth discoloration and skeletal problems in children and fetusus)

Question 1065

The hallmark erythema migrans rash in a pt w/ a tick bite hx is pathognomonic for early localized Lyme disease. Doxycycline is the tx of choice in pts who are not pregnant and > 8 years old.

Answer 1065

.

Question 1066

Contraindications to rotavirus vaccine

Answer 1066

- anaphylaxis to vaccine ingredients - hx of intussusception - hx of uncontrolled congenital malformation of the GI tract (eg Meckel's diverticulum) - SCID

Question 1067

what are the only treatments that have been shown to decrease mortality in pts w/ COPD?

Answer 1067

- smoking cessation | - home oxygen therapy

Question 1068

when should an echo be obtained?

Answer 1068

-in all pts w/ syncope due to suspected STRUCTURAL HEART DISEASE

Question 1069

Preeclampsia

Answer 1069

HTN, proteinuria, edema

Question 1070

arm position in anterior shoulder dislocation

Answer 1070

abducted and externally rotated

Question 1071

arm position in posterior shoulder dislocation

Answer 1071

-adducted and internally rotated

Question 1072

Magnesium toxicity

Answer 1072

-N/V/D, muscle weakness, and DECREASED or ABSENT DTRs@

Question 1073

Indications for GBS prophylaxis when GBS status is unknown

Answer 1073

- delivery at 18 hours - GBS bacteriuria in any concentration during the current pregnancy - prior hx of delivery of an infant w/ GBS sepsis

Question 1074

antenatal corticosteroids

Answer 1074

- should be administered in pregnant females w/ PPROM before 32 wks gestation to reduce risks of respiratory distress syndrome, necrotizing enterocolitis, neonatal intraventricular hemorrhage, and neonatal death - beyond 32 wks, its unclear if steroids are efficacious w/ rupture of membranes, though many places continue to administer betamethasone between 32-34 wks for pts w/ PPROM; - steroids are typically not given after 34 wks gestation

Question 1075

Pts w/ PPROM whose GBS status is unknown should receive antibiotics. If a woman is admitted to the hospital after 34 wks gestation w/ PPROM, delivery is usually recommended.

Answer 1075

.

Question 1076

Pts w/ severe BPH can eventually progress to urinary obstruction and renal failure. A renal US is advised for assessment of hydronephrosis and worsening kidney function.

Answer 1076

.

Question 1077

emergency contraceptive options

Answer 1077

- copper IUD (most effective; 99%; can be used up to 5 days after) - Levonorgestrel pill (85%; used up to 3 days after) - Ulipristal pill (> 85%; used up to 5 days after) - OCPs (75%; used up to 3 days after)

Question 1078

congenital CMV

Answer 1078

- can cause developmental delay - sensorineural deafness - blindness - jaundice - hepatosplenomegaly - petechiae

Question 1079

Fetal hydantoin syndrome

Answer 1079

- due to pregnant women on phenytoin | - hypoplastic fingers/nails and cleft lip/palate

Question 1080

congenital rubella syndrome

Answer 1080

- developmental delay - sensorineural deafness - cataracts - hepatosplenomegaly - purpura

Question 1081

Measles

Answer 1081

- cough, coryza, conjunctivitis, and Koplik spots followed by a maculopapular rash that spreads in a cranial-caudal pattern - prevention is best through live attenuated measles vaccine

Question 1082

Specific phobia

Answer 1082

- fear of a specific object or situation | - behavioral therapy using exposure techniques is the preferred treatment

Question 1083

Cerebral palsy

Answer 1083

- group of syndromes characterized by nonprogressive motor dysfunction - etiology is multifactorial, w/ prematurity as the leading risk factor - affected pts have uncoordinated and limited voluntary movements

Question 1084

biggest risk factor for cerebral palsy

Answer 1084

prematurity

Question 1085

For women w/ average risk for cervical cancer, a Pap test is recommended every 3 yrs from age 21-29. Between ages 30-65, pts w/ initial negative testing may have either a Pap test alone every 3 yrs or a combination of Pap test and HPV testing every 5 years (preferred).

Answer 1085

.

Question 1086

Screening for diabetes

Answer 1086

- recommended in pts w/ sustained BP > 135/80 mmHg and may be considered in all pts over age 45, as well as those w/ additional risk factors for diabetes - screening options include fasting plasma glucose, 2 hr oral glucose tolerance test and hemoglobin A1c

Question 1087

Trachoma

Answer 1087

- caused by Chlamydia trachomatis serotype A-C - major cause of blindness worldwide - presents w/ follicular conjunctivitis and pannus (neovascularization) formation in the cornea - diagnosed by Giemsa stain exam of conjunctival scrapings - topical tetracycline or oral azithromycin should be started immediately

Question 1088

Herpes simplex karatitis

Answer 1088

- pain, photophobia, and decreased vision | - dendritic ulcer is most common presentation, may also have minute clear vesicles on corneal epithelium

Question 1089

Gonococcal conjunctivitis

Answer 1089

- acquired through contact w/ infected genital secretions, and occurs 2-3 days after birth - presents as copious, purulent eye discharge w/ swollen eyelids and chemosis

Question 1090

viral conjunctivitis

Answer 1090

- conjunctiva is red w/ copious, watery discharge - children more commonly infected through contaminated swimming pools - mostly caused by adenovirus type 3

Question 1091

acid-base relationship w/ calcium

Answer 1091

- increased extracellular pH (eg respiratory alkalosis) causes dissociation of hydrogen ions from albumin, allowing increased binding of calcium and a drop in unbound (ionized) calcium - ionized calcium is the physiologically active form, and decreased levels can result in clinical manifestations of hypocalcemia (crampy pain, paresthesias, carpopedal spasm)

Question 1092

Edward's syndrome

Answer 1092

-commonly present w/ microcephaly, prominent occiput, micrognathia, closed fists w/ index finger overlapping the 3rd digit and the 5th digit overlapping the 4th, and rocker bottom feet

Question 1093

Patau's syndrome (trisomy 13)

Answer 1093

-cleft lip, flexed fingers w/ polydactyly, ocular hypotelorism, bulbous nose, low-set malformed ears, small abnormal skull, cerebral malformation, microphthalmia, cardiac malformations, scalp defects, etc.

Question 1094

Toxic shock syndrome

Answer 1094

- due to Staph aureus; associated w/ menstruation (tampons), nasal packing, and post-surgery infections - pts usually develop fever, myalgias, marked hypotension, and diffuse erythematous macular rash (erythroderma) that can progress to multiorgan involvement

Question 1095

Scarlet fever

Answer 1095

- primarily seen in children - group A strep infection occurs earlier at another site (tonsillitis, pharyngitis) - skin findings are preceded by prodrome of fever, headache, vomiting, and sore throat - 12-48 hrs later, fine pink blanching papules appear on the neck and upper trunk and quickly generalize w/ flexural accentuation (rough, sandpaper-like texture)

Question 1096

Daughters of women who received diethylstilbestrol during pregnancy are at increased risk of developing clear cell adenocarcinoma of the vagina and cervix. In addition, daughters and sons w/ in-utero exposure are at risk for genital tract anomalies.

Answer 1096

.

Question 1097

risk factors for squamous cell carcinoma of the cervix and vagina

Answer 1097

-HPV and tobacco

Question 1098

Multiple myeloma

Answer 1098

- plasma cell disorder | - presents w/ lytic lesions, hypercalcemia, and renal failure

Question 1099

Autosomal dominant polycystic kidney disease

Answer 1099

- usually present w/ HTN, hematuria, proteinuria, palpable renal masses, or progressive renal insufficiency - may also have flank pain due to renal calculi, cyst rupture or hemorrhage, or upper UTI - HTN is a common early finding in pts w/ ADPKD and usually precedes the decline in renal function

Question 1100

HIV and hep C infection should be suspected in pts w/ weight loss and hx of IV drug abuse. Pts w/ HIV are at risk of developing depression and dementia.

Answer 1100

.

Question 1101

Inhaled anti-muscarinic agents such as ipratropium are the mainstay of symptom management in COPD. These anti-cholinergic meds may be combined w/ short acting beta agonists for greater symptom relief.

Answer 1101

.

Question 1102

Epidermal inclusion cyst

Answer 1102

- benign nodule containing normal epidermis that produces keratin - pts usually develop a dome-shaped, firm, freely movable cyst or nodule w/ a small central punctum - the lesion can remain stable or gradual increase in size but usually resolves spontaneously

Question 1103

Gastrinoma (Zollinger-Ellison syndrome)

Answer 1103

- suspect in pts w/ multiple stomach ulcers and thickened gastric folds on endoscopy - diagnosis is strongly suggested by a fasting serum gastrin level > 1000 pg/mL - pts w/ non-diagnostic serum gastrin levels should be evaluated w/ a secretin stimulation test

Question 1104

triple therapy for H. pylori

Answer 1104

PPI, amoxicillin, clarithromycin

Question 1105

Bowel ischemia and infarction are possible early complications of operation on the abdominal aorta, such as AAA repair.

Answer 1105

.

Question 1106

Pronator drift

Answer 1106

- relatively sensitive and specific physical exam finding for upper motor neuron damage affecting the upper extremities - some stroke pts will demonstrate pronator drift in the absence of other significant findings

Question 1107

Dressler's syndrome

Answer 1107

- presents weeks after a MI w/ chest pain that is improved by leaning forward - NSAIDs are the treatment of choice - anticoagulation should be avoided to prevent development of a hemorrhagic pericardial effusion

Question 1108

Pts w/ esophageal dysphagia can initiate swallowing but have difficulty passing food down the esophagus. Dysphagia initially with solids and eventually liquids is likely due to a mechanical obstruction; dysphagia which affects solids and liquids from the onset is more likely due to a motility disorder. Barium swallow is recommended initially for suspected motility disorders, followed by motility studies (manometry) to confirm the diagnosis

Answer 1108

.

Question 1109

tx of acute limb ischemia

Answer 1109

-start IV heparin immediately upon suspicion; definitive tx is surgical embolectomy or intra-arterial fibrinolysis/mechanical embolectomy via interventional radiology

Question 1110

Cilostazol

Answer 1110

- inhibits platelet aggregation and causes vasodilation | - sometimes used to treat chronic claudication

Question 1111

Sickle cell is usually a chronic normocytic, hemolytic anemia w/ appropriate reticulocytosis response. Folate deficiency can occur due to increased RBC turnover and increased consumption of folate in the bone marrow. Daily folic acid supplementation is recommended in all SCD pts.

Answer 1111

.

Question 1112

Diastolic and continuous murmurs as well as loud systolic murmurs should always be investigated using TTE. Midsystolic soft murmurs in an asymptomatic young patient are usually benign and need no further work-up.

Answer 1112

.

Question 1113

Contrast administration has the potential to cause contrast-induced nephropathy, particularly in pts w/ renal insufficiency (Cr > 1.5) and/or diabetes. Non-ionic contrast agents are associated w/ lower incidence of nephropathy than the older ionic hyperosmolar agents. In addition, adequate IV hydration and acetylcysteine can decrease the incidence of nephropathy.

Answer 1113

.

Question 1114

Granulomatosis w/ polyangiitis (Wegener's)

Answer 1114

- triad of systemic vasculitis, upper and lower airway granulomatous inflammation, and glomerulonephritis - nasal cartilage destruction and vasculitic cutaneous lesions (tender nodules, palpable purpura, ulcerations) are common external manifestations

Question 1115

Primary Raynaud phenomenon

Answer 1115

- increased vascular response to cold temperature or emotional stress - usually found in women age

Question 1116

Uremic pericarditis (UP)

Answer 1116

- occurs in 6-10% of renal failure pts, typically those w/ BUN levels > 60 mg/dL - most UP pts do not present w/ the classic ECG changes of pericarditis (eg diffuse ST segment elevation) - hemodialysis leads to rapid resolution of chest pain and reduces the size of any associated pericardial effusion

Question 1117

Hypertrophic cardiomyopathy (HCM)

Answer 1117

- autosomal dominant genetic disorder caused by mutation in one of several genes encoding the myocardial contractile proteins of the cardiac sarcomere - mutations in the cardiac myosin binding protein C gene and cardiac beta-myosin heavy chain gene are responsible for about 70% of identifiable mutations in pts w/ HCM

Question 1118

Howell-Jolly bodies

Answer 1118

- nuclear remnants within RBCs typically removed by the spleen - their presence strongly suggests physical or functional hyposplenism

Question 1119

Heinz bodies

Answer 1119

- hemoglobin precipitation seen in G6PD deficiency - hemoglobin becomes oxidized and forms insoluble precipitants - appear after staining w/ crystal violet dye

Question 1120

Rectal bleeding does NOT usually occur in the setting of ACUTE diverticulitis

Answer 1120

.

Question 1121

Bowel ischemia may complicate up to 7% of procedures on the aortoiliac vessels and most commonly affects the distal left colon. Pts report dull pain over the ischemic bowel as well as hematochezia. Colonoscopy shows a discrete segment of cyanotic and ulcerated bowel.

Answer 1121

.

Question 1122

hydrocele

Answer 1122

- most cases will disappear spontaneously by the age of 12 months and can be safely observed during that period - those that do NOT resolve spontaneously should be removed surgicallly due to risk of inguinal hernia

Question 1123

Performance-related anxiety

Answer 1123

- classified as social anxiety disorder, performance-only type - PRN beta-blockers or benzo's in pts w/o hx of substance abuse - CBT

Question 1124

Lyme arthritis

Answer 1124

- most common late manifestation of untreated Lyme disease | - synovial fluid typically about 25,000 WBC

Question 1125

Threatened abortion

Answer 1125

-any hemorrhage occurring before the 20th wk of gestation w/ a live fetus and closed cervix

Question 1126

most common organisms responsible for epiglottitis, especially in adult population

Answer 1126

H. influenza and Strep pyogenes

Question 1127

Chronic HTN w/ superimposed preeclampsia

Answer 1127

-HTN that occurs before pregnancy or before 20 weeks gestation w/ subsequent development of proteinuria

Question 1128

Alpha-1 antitrypsin deficiency

Answer 1128

-associated w/ panacinar emphysema and cirrhosis

Question 1129

most common cause of nephrotic syndrome in children

Answer 1129

minimal change disease - light microscopy shows normal architecture - EM shows effacement of foot processes - no biopsy if under 10 - tx w/ steroids

Question 1130

most common cause of nephrotic syndrome in adults

Answer 1130

FSGS

Question 1131

second most common cause of nephrotic syndrome in adults

Answer 1131

membranous glomerulonephritis (thickened BM, subepithelial spikes)

Question 1132

Histoplasma capsulatum

Answer 1132

- common and usually asymptomatic infection in endemic areas like Mississippi and Ohio River valleys and Central America - usually found in soil w/ a high concentration of bird or bat guano droppings

Question 1133

Folic acid and cobalamin deficiencies both cause a macrocytic anemia w/ hypersegmented neutrophils. Deficiencies in either nutrient will result in increased homocysteine levels because both are involved in converting homocysteine to methionine. Only cobalamin deficiency, however, will cause an increase in methylmalonic acid (converts methylmalonyl-CoA to succinyl-CoA)

Answer 1133

.

Question 1134

normal osmolar gap

Question 1135

rectangular, envelope-shaped crystals

Answer 1135

- calcium oxalate crystals | - ethylene glycol poisoning

Question 1136

Newborns of mothers w/ active hepatitis B infection should be passively immunized at birth w/ hepatitis B immune globulin followed by active immunization w/ recombinant HBV vaccine.

Answer 1136

.

Question 1137

Pemphigus vulgaris

Answer 1137

- mucocutaneous blistering disease that is characterized by flaccid bullae and intercellular IgG deposits in the epidermis - autoantibodies are formed against desmoglein, an adhesion molecule

Question 1138

Bullous pemphigoid

Answer 1138

- benign pruritic disease characterized by tense blisters | - immunofluorescence shows IgG and C3 deposits in the dermal-epidermal junction

Question 1139

Inflammatory acne

Answer 1139

- tx w/ topical retinoids and benzoyl peroxide - moderate and moderate to severe cases will benefit from the addition of topical antibiotics - oral abx and isotretinoin are usually reserved for severe or recalcitrant acne

Question 1140

Diabetic autonomic neuropathy

Answer 1140

- can affect the GU tract to cause a neurogenic bladder w/ urinary retention and distended bladder - pts can then develop overflow incontinence (eg dribbling, poor urinary stream) w/ a high post-void residual volume

Question 1141

Hemophilia A and B

Answer 1141

- X-linked recessive bleeding disorders from factor VIII (A) and IX (B) deficiency - recurrent hemarthrosis and skeletal muscle hemorrhage after mild trauma are the most common manifestations of this disorder - hematuria is also seen, but renal function is usually normal

Question 1142

what should you suspect in a young female w/ bilateral trigeminal neuralgia?

Answer 1142

Multiple sclerosis

Question 1143

what is atrophied in Huntington's disease?

Answer 1143

Caudate nucleus

Question 1144

what is a well-known complication of giant cell or temporal arteritis?

Answer 1144

- Aortic aneurysms (due to involvement of the branches of the aorta) - pts should be followed w/ serial chest x-rays

Question 1145

causes of membranous glomerulonephritis

Answer 1145

-hepatitis B and C, syphilis, gold, penicillamine, SLE, and rheumatoid arthritis

Question 1146

frostbite injuries

Answer 1146

- best tx is rapid re-warming w/ warm water - NO ATTEMPT SHOULD BE MADE TO DEBRIDE ANY TISSUE INITIALLY; true demarcation between dead and viable tissue may take weeks

Question 1147

Give the appropriate pain medications to cancer pts. Do NOT be afraid to use a narcotic drug if it is the most appropriate.

Answer 1147

.

Question 1148

Inactivation of pancreatic enzymes by increased production of stomach acid may lead to malabsorption in pts w/ Zollinger-Ellison syndrome

Answer 1148

.

Question 1149

Warfarin-induced skin necrosis

Answer 1149

- typically occurs within the first few days of warfarin therapy - caused by a rapid decline in protein C levels, usually in pts w/ underlying hereditary protein C deficiency - tx involves immediate warfarin cessation and administration of protein C concentrate

Question 1150

Heparin-induced thrombocytopenia

Answer 1150

-caused by autoantibodies to platelet factor 4 (PF4) complexed w/ heparin, and is characterized by thrombocytopenia, arterial or venous thrombosis, and necrotic skin lesions at heparin injection sites within 5-10 days of therapy

Question 1151

antithrombin III

Answer 1151

- vitamin K-independent inhibitor of the clotting cascade | - antithrombin III deficiency predisposes to thrombus formation

Question 1152

Factor V Leiden mutation

Answer 1152

-increases the risk of venous thromboembolism -also increase risk of cerebral, mesenteric, and portal vein thrombosis -

Question 1153

alcohol withdrawal

Answer 1153

- develop signs between 12-48 hrs after last drink - acute stage: sweating, hyperreflexia, tremors, and seizures - next is acute hallucinosis in the absence of autonomic symptoms - final stage is delirium tremens: altered sensorium, hallucinations, autonomic instability (tachycardia, fever, sweating)

Question 1154

Beta blocker overdose

Answer 1154

- presents w/ bradycardia, hypotension, wheezing, hypoglycemia, delirium, seizures, and cardiogenic shock - IV fluids and atropine are first-line tx - IV glucagon should be administered in pts w/ profound or refractory hypotension

Question 1155

Aminophylline

Answer 1155

- methylxanthine which acts by blocking phosphodiestease, thereby increasing levels of cAMP - causes bronchodilation and has positive inotropic/chronotropic effects

Question 1156

symptoms of digoxin toxicity

Answer 1156

- life threatening arrhythmias - anorexia, N/V, abdominal pain - fatigue, confusion, weakness, CHANGES IN COLOR VISION

Question 1157

Congenital hypothyroidism

Answer 1157

- associated w/ neurodevelopmental injury if not recognized and treated early - decreased activity, hoarse cry, jaundice; majority of infants are asymptomatic though - thyroid dysgenesis is the most common cause worldwide

Question 1158

what is the opening pressure in idiopathic intracranial HTN?

Answer 1158

> 250 mm H2O

Question 1159

The classic VSD murmur is harsh, holosystolic murmur best heard at the left lower sternal border. Echo should be performed to determine the location and size of the defect and to rule out other defects. Most small VSD close spontaneously and require no treatment.

Answer 1159

.

Question 1160

Best diagnostic test for diverticulitis in the acute setting?

Answer 1160

Abdominal CT -look for inflammation in pericolic fat, presence of diverticula, bowel wall thickening, soft tissue masses (eg phlegmons), and pericolic fluid collections suggesting abscess

Question 1161

Ruptured ovarian cyst

Answer 1161

- presents w/ acute onset of unilateral pelvic pain immediately after strenuous activity or sexual intercourse - pelvic US can show free fluid in the pelvis - supportive care (eg analgesics) is recommended for uncomplicated cyst rupture; complicated rupture may require surgical intervention

Question 1162

Respiratory distress syndrome

Answer 1162

- caused by surfactant deficiency - important risk factors include prematurity and maternal diabetes mellitus - fetal hyperglycemia causes hyperinsulinemia, which antagonize cortisol and block the maturation of sphingomyelin

Question 1163

Choanal atresia

Answer 1163

- should be suspected in an otherwise well-appearing infant w/ intermittent cyanosis and distress during feeding that is relieved by crying - failure to pass a catheter through the nose into the oropharynx is suggestive of the diagnosis - a CT scan shows narrowing at the level of the pterygoid plate in the posterior nasal cavity

Question 1164

First-line tx for OCD

Answer 1164

SSRI or clomipramine

Question 1165

acetaminophen toxicity

Answer 1165

-causes centrilobular or diffuse hepatocyte necrosis

Question 1166

alcoholic hepatitis on histopathology

Answer 1166

-hepatocyte swelling and necrosis, Mallory bodies, and neutrophilic infiltration

Question 1167

Primary sclerosing cholangitis

Answer 1167

-periductal portal tract fibrosis and segmental stenosis of extrahepatic and intrahepatic bile ducts

Question 1168

Severe pain in a patient w/ a mild urinary obstruction, such as BPH, may cause urinary retention due to inability to Valsalva.

Answer 1168

.

Question 1169

Amiodarone

Answer 1169

-class 3 antiarrhythmic agent frequently used for conversion and maintenance of sinus rhythm in pts w/ AF

Question 1170

Antithrombotic therapy w/ warfarin (or other anticoagulants such as dabigatran, rivaroxaban, and apixaban) is the most effective way to reduce the risk of systemic embolization in pts w/ nonvalvular AF. Risk stratification w/ the CHADS2 scoring system should be used in all AF pts to assess the need for long-term anticoagulation.

Answer 1170

.

Question 1171

Hypothyroidism should always be considered in pts w/ an unexplained elevation of serum creatine kinase concentration and myopathy. ANA may be positive in pts w/ Hashimoto's thyroiditis. Serum TSH is the most sensitive test to diagnose hypothyroidism

Answer 1171

.

Question 1172

Secondary amyloidosis

Answer 1172

- complication of a chronic inflammatory condition (eg chronic infections, IBD, rheumatoid arthritis) resulting in extracellular tissue deposition of fibrils into tissues and organs. - pts can develop multi organ dysfunction (eg kidneys, liver, GI) - tx involves treating the underlying condition and Colchicine

Question 1173

differentiate preseptal vs orbital cellulitis

Answer 1173

- preseptal cellulitis is a mild infection of the eyelid anterior to the orbital septum - orbital cellulitis is a serious infection posterior to the orbital septum - orbital cellulitis causes pain w/ extraocular movements, diplopia, and ophthalmoplegia - dangerous complications include blindness and intracranial infection from orbital cellulitis

Question 1174

surgery is rarely needed for MCL tears; bracing and early ambulation is the preferred treatment.

Answer 1174

.

Question 1175

Antiphospholipid antibody syndrome

Answer 1175

- associated w/ false positive VDRL, prolonged PTT, and thrombocytopenia - can promote arterial and venous thromboses and a resultant tendency toward spontaneous abortions - prophylaxis w/ low dose aspirin and LMWH are recommended to avoid pregnancy loss

Question 1176

Meningococcal vaccination

Answer 1176

- should be provided to all adolescents at age 11-12 - a booster is recommended at age 16 - esp. important for military recruits, college students living in dorms, and travelers to sub-Saharan africa

Question 1177

most common cause of viral meningitis

Answer 1177

the non-polio enteroviruses, such as echoviruses and coxsackieviruses

Question 1178

Erythema toxicum neonatorum

Answer 1178

- benign neonatal rash characterized by blanching erythematous papules and/or pustules - resolves spontaneously within 2 wks after birth

Question 1179

Maternal comorbidities such as chronic HTN require antepartum fetal surveillance to diagnose fetal compromise and prevent death. Nonstress tests should be performed at least weekly in the third trimester until delivery. A normal result consists of 2 heart rate accelerations and is reassuring.

Answer 1179

.

Question 1180

most common predisposing factor for acute bacterial sinusitis

Answer 1180

viral URI

Question 1181

Ludwig's angina

Answer 1181

- infection of the submandibular and sublingual glands - the source of infection is most commonly an infected tooth, usually the second or third mandibular molar - asphyxiation is the most common cause of death in this disease - pts present w/ fever, dysphagia, odynophagia, and drooling

Question 1182

first-line pharmacotherapy for enuresis

Answer 1182

- Desmopressin - it can provide immediate improvement for frustrated families when behavior modifications and alarm therapy have failed but has a high rate of relapse if used alone

Question 1183

Loss of consciousness is seen w/ complex partial seizures and partial seizures w/ secondary generalization, but not simple partial seizures. Pts w/ complex partial seizures typically have AUTOMATISMS during their loss of consciousness; these activities include chewing, picking movements of the hands, and lip smacking. In contrast, pts w/ a partial seizure with secondary generalization usually have tonic-clonic manifestations (diffuse muscle aches, elevated CPK).

Answer 1183

.

Question 1184

Noninvasive evaluation w/ compression US is recommended as an initial test in pts w/ moderate or high probability of DVT. In pts w/ low probability, a D-dimer assay can further assess risk, w/ an US performed only in pts w/ a positive D-dimer.

Answer 1184

.

Question 1185

A young woman who presents w/ a breast lump can be asked to return after her menstrual period for reexamination (which may reveal regression of the mass) if no obvious signs of malignancy are present.

Answer 1185

.

Question 1186

tx option for psoriatic arthritis

Answer 1186

NSAIDS, methotrexate, anti-TNF agents

Question 1187

VIPoma

Answer 1187

- rare tumor affecting the pancreatic cells that produce VIP - most pts develop VIPoma syndrome (pancreatic cholera) w/ watery diarrhea, muscle weakness/cramps (due to hypokalemia), and hypo- or achlorhydria (due to decreased gastric acid secretion) - stool studies are consistent w/ secretory diarrhea; a VIP level > 75 pg/mL confimrs the diagnosis - most are located in the tail of the pancreas

Question 1188

Carcinoid syndrome

Answer 1188

- flushing, diarrhea, bronchospasm | - 70-80% arise in small intestine

Question 1189

Hypocalcemia

Answer 1189

- can occur during or immediately after surgery in pts undergoing major surgery and requiring extensive transfusions - HYPERactive deep tendon reflexes may be the initial manifestation

Question 1190

any pt who returns from a developing country and has symptoms suggestive of malabsorption should be considered for empirical tx w/ metronidazole for giardiasis. Remember the pathophysiology (adhesive disks and malabsorption)

Answer 1190

.

Question 1191

what is the most common complication of peptic ulcer disease?

Answer 1191

hemorrhage!

Question 1192

Paget's disease of bone

Answer 1192

- abnormal bone remodeling in "mosaic" pattern - many pts are asymptomatic and are diagnosed after an isolated elevation in alkaline phosphatase is noted on lab testing - headaches, increased head size, hearing loss, and compression of cranial nerves, spinal cord, or spinal nerve roots

Question 1193

in the absence of identifiable bacteria on culture or Gram stain, a mucopurulent urethral discharge in a pt who is sexually active suggests chlamydial urethritis. Nucleic acid amplification testing confirms the diagnosis.

Answer 1193

.

Question 1194

Asymptomatic diverticulosis needs only dietary modifications in the form of HIGH FIBER INTAKE.

Answer 1194

.

Question 1195

Burr cells

Answer 1195

- aka echinocytes | - spiculated RBCs seen in liver disease and end-stage renal disease

Question 1196

Howell-Jolly bodies

Answer 1196

- basophilic nuclear remnants that appear as small, black pellets in RBCs - seen in pts w/ hx of splenectomy or functional asplenia

Question 1197

Spur cells

Answer 1197

- aka acanthocytes | - RBCs w/ irregularly sized and spaced projections that are most commonly seen in liver disease

Question 1198

Scleroderma renal crisis

Answer 1198

- typically presents w/ acute renal failure (w/o previous kidney disease) and malignant HTN (eg headache, blurry vision, nausea). - UA may show mild proteinuria - peripheral blood smear can show microangiopathic hemolytic anemia w/ schistocytes and thrombocytopenia

Question 1199

Initial hematuria suggests urethral damage. Terminal hematuria indicates bladder or prostatic damage, and total hematuria reflects damage in the kidney or ureters. Clots are NOT usually seen w/ renal causes of hematuria.

Answer 1199

.

Question 1200

Histoplasma

Answer 1200

- usually causes an asymptomatic or minor respiratory illness in healthy pts, but immunocompromised pts can develop severe pulmonary or disseminated disease - the most rapid and sensitive test to diagnose disseminated histoplasmosis in immunocompromised pts is URINE or SERUM assay for Histoplasma antigen

Question 1201

preferred antifungal tx for histoplasmosis?

Answer 1201

Itraconazole for mild to moderate disease. Amphotericin B for severe disease

Question 1202

COPD is characterized by progressive expiratory airflow limitation which causes air trapping, decreased VC and increased TLC. FEV1 is disproportionately decreased as compared to VC.

Answer 1202

.

Question 1203

Germ cell tumors typically affect young pts and display aggressive biologic behavior. Nonseminomatous germ cell tumors typically produce BOTH alpha fetoprotein and b-HCG! Also often present with anterior mediastinal mass.

Answer 1203

.

Question 1204

Congenital syphilis

Answer 1204

- presents early on w/ hepatosplenomegaly, cutaneous lesions, jaundice, anemia, and rhinorhea - metaphyseal dystrophy and periostitis may be seen on radiography

Question 1205

blueberry muffin rash

Answer 1205

congenital rubella

Question 1206

congenital CMV

Answer 1206

-intrauterine growth restriction, hepatosplenomegaly, petechiae or purpura, microcephaly, chorioretinitis, sensorineural hearing loss, and periventricular calcifications

Question 1207

mesna

Answer 1207

-used to prevent hemorrhagic cystitis caused by cyclophosphamide

Question 1208

n-acetylcysteine

Answer 1208

-antidote for acetaminophen overdose and nephroprotective agent to prevent radiocontrast-induced nephropathy

Question 1209

Gout

Answer 1209

- can result from overproduction or underexcretion of uric acid - induction chemo results in rapid tumor cell lysis and releases uric acid into the circulation - distinguish between prevention and tx of gout: for prevention, allopurinol and probenecid are use; for tx during acute attacks, NSAIDs, colchicine, and steroids are used

Question 1210

Allopurinol inhibits xanthine oxidase, which results in decrease PRODUCTION of uric acid. Probenecid increases uric acid excretion and has a slight increased risk of uric acid kidney stones with use.

Answer 1210

.

Question 1211

Lactose intolerance

Answer 1211

- diagnosis: improvement after abstaining from dairy; acid pH of stool; presence of positive reducing sugars - confirmed by HYDROGEN BREATH TEST

Question 1212

HUS

Answer 1212

- suspect in child w/ sudden-onset abdominal pain, bloody diarrhea, and triad of anemia, thrombocytopenia, and renal failure - tx is supportive; possibly plasmapheresis

Question 1213

pericardial effusion

Answer 1213

- appears as an enlarged, "water bottle" shaped cardiac silhouette on CXR - physical exam findings of effusion w/o cardiac tamponade include diminished heart sounds on auscultation and a difficult to palpate PMI

Question 1214

conditions w/ an S4 heart sound

Answer 1214

-hypertensive heart disease, aortic stenosis, hypertrophic cardiomyopathy, acute phase of MI

Question 1215

all children w/ recurrent episodes of nocturnal vulvar itching should be examined for pinworms and tx empirically w/ MEBENDAZOLE.

Answer 1215

.

Question 1216

Pts w/ severe aortic stenosis can have anginal chest pain due to increased myocardial oxygen demand

Answer 1216

.

Question 1217

Bedwetting is normal before age 5. Mastery of nighttime continence can take months to years, and boys generally achieve this milestone later than girls.

Answer 1217

.

Question 1218

SABAs administered 10-20 minutes before exercise are the first-line tx for exercise-induced bronchoconstriction if required only a few times a week (less than daily). Inhaled corticosteroids or anti-leukotriene agents can be used in pts who exercise daily.

Answer 1218

.

Question 1219

Riedel's (fibrous) thyroiditis

Answer 1219

- inflammatory disorder characterized by fibrosclerosis of the thyroid, surrounding tissues, and often remote nonthyroidal structures (eg retroperitoneum) - subclinical or overt hypothyroidism may be seen, but most pts have a hard goiter

Question 1220

any patient w/ an acute, severe illness may have abnormal thyroid function tests. Euthyroid sick syndrome ("low T3 syndrome") is characterized by a fall in total and free T3 levels w/ normal T4 and TSH levels.

Answer 1220

.

Question 1221

Platelet dysfunction is the most common cause of abnormal hemostasis in pts w/ chronic renal failure. PT, PTT, and platelet count are normal. Bleeding time is prolonged. DDAVP is usually the tx of choice, if needed. DDAVP increases the release of factor VIII: von Willebrand factor multimers from endothelial storage sites. Platelet transfusion is not indicated because the transfused platelets quickly become inactive

Answer 1221

.

Question 1222

Angiodysplasia

Answer 1222

- common cause of recurrent or occult painless lower GI bleeding in pts age > 60 years - they have been reported to cause lower GI bleeding in pts w/ aortic stenosis (Heyde's syndrome) and end-stage renal disease due to increased bleeding risk in these pts unmasking sites prone to bleeding

Question 1223

Nephrotic syndrome

Answer 1223

- defined by: Proteinuria (> 3.5 g/day), hypoalbuminemia, edema, hyperlipidemia and lipiduria - HYPERCOAGULABLE condition which manifests as venous or arterial thrombosis, and even PE - renal vein thrombosis is the most frequent manifestation - complications include: protein malnutrition, iron-resistant microcytic hypochromic anemia, increased susceptibility to infection, and vitamin D deficiency

Question 1224

obstructive vs restrictive lung disease

Answer 1224

-obstructive: FEV1 70%, FVC

Question 1225

Asthma diagnosis

Answer 1225

- can be diagnosed in late adulthood - confirmed by PFTs - reversible airway obstruction (>12% increase in FEV1) w/ normal diffusion capacity for carbon monoxide suggest asthma regardless of age

Question 1226

organism responsible for Kaposi sarcoma?

Answer 1226

-human herpesvirus-8 (HHV-8)

Question 1227

Dermatofibromas

Answer 1227

-nontender, firm, hyperpigmented nodules that are usually

Question 1228

Febrile nonhemolytic transfusion reaction

Answer 1228

- most common adverse reaction that occurs within 1-6 hrs of transfusion - pts usually develop fever, chills, and malaise w/o hemolysis - leukoreduction of donor blood can prevent febrile nonhemolytic reaction and reduce the risk of HLA alloimmunization and CMV transmission

Question 1229

a reciprocal translocation of chromosomes 9 and 22 can form the Philadelphia chromosome containing the BCR/ABL fusion gene, which is characteristic of CML. Tyrosine kinase inhibitors, which function by inhibiting the abnormal BCR/ABL gene, are a key component of tx for CML.

Answer 1229

.

Question 1230

Adhesive capsulitis

Answer 1230

- results from chronic inflammation, fibrosis, and contracture of the joint capsule - pts experience shoulder stiffness out of proportion to pain, and exam shows reduction of both passive and active ROM

Question 1231

Hepatojugular reflux

Answer 1231

- clinically useful to differentiate between cardiac and liver disease-related causes of lower extremity edema - pts w/ peripheral edema due to heart failure have elevated JVP and positive hepatojugular reflux - those w/ peripheral edema from primary hepatic disease and cirrhosis have reduced or normal JVP and negative hepatojugular reflux

Question 1232

The proximal deep leg veins are the most common source of symptomatic pulmonary embolism. Other less common sources of emboli include the calf veins, renal veins, pelvic veins, upper extremity veins, and right heart.

Answer 1232

.

Question 1233

Copious purulent ocular drainage and eyelid swelling in a 2 to 5 day old newborn are most consistent w/ what?

Answer 1233

- Gonococcal conjunctivitis - can be prevented w/ application of topical erythromycin ointment within 1 hr of birth - conjunctivitis caused by Chlamydia trachomatis is usually milder and presents 5-14 days after birth

Question 1234

Pts w/ Turner syndrome have a higher risk of osteoporosis due to lower estrogen levels and only having one copy of X chromosome genes involved in bone metabolism.

Answer 1234

.

Question 1235

the most common and feared complication associated w/ TPN?

Answer 1235

catheter tip infection

Question 1236

Nonstress test (NST)

Answer 1236

- administered in high risk pregnancies to assess for fetal hypoxemia - considered reactive if there are 2 or more heart rate acclerations of 15 bpm above baseline that last for 15 seconds over 20 minutes of observation

Question 1237

Ecthyma gangrenosum

Answer 1237

- associated w/ Pseudomonas aeruginosa bacteremia that is characterized by rapidly progressive skin lesions that develop into nontender nodules w/ central necrosis - can be seen in pts who are immunocompromised, and tx should consist of anti-pseudomonal antibiotics

Question 1238

Pts w/ chest pain, signs of decreased cardiac output, and pulsus paradoxus following a viral infection most likely have cardiac tamponade resulting from acute pericarditis. In this setting, right atrial filling is impaired, which results in an increase in the systemic venous pressure. However, the lungs remain clear to auscultation because there is no backup of blood into the pulmonary circulation.

Answer 1238

.

Question 1239

Pulmonary fibrosis

Answer 1239

- causes decreased compliance of the lungs, and spirometry typically reveals decreased TLC, decreased FVC, decreased FEV1, and a normal FEV1/FVC ratio - bibasilar fine, dry crackles are typically heard on auscultation - note that normal values for FEV1 and the FEV1/FVC ratio are between 80% - 120% of predicted values!!!!

Question 1240

spirometry findings in COPD

Answer 1240

-decreased FEV1, normal FVC, decreased FEV1/FVC ratio

Question 1241

Paraneoplastic Cushing syndrome

Answer 1241

- most commonly caused by ectopic ACTH production by SMALL CELL LUNG CARCINOMA - hyperpigmentation is frequently present and is due to coproduction of melanocyte-stimulating hormone w/ ACTH

Question 1242

overproduction of amino acid-derived hormomes

Answer 1242

-typically seen in neuroendocrine tumors, such as carcinoid (serotonin) or pheochromocytoma (norepinephrine, epinephrine)

Question 1243

Protraction of labor

Answer 1243

- refers to a slow progression of cervical dilatation, whereas arrest disorders are diagnosed when the cervix ceases to dilate after reaching at least 4 cm - if the membranes are still intact, an amniotomy is usually the first step to promote the progression of labor

Question 1244

Tuberculosis

Answer 1244

- common cause of pleural effusions - the effusion is exudative w/ protein concentrations often greater than 4 g/dL - the fluid also consists of a lymphocytic leukocytosis w/ no gross purulence and a glucose concentration typically mildly below the serum glucose level

Question 1245

causes of exudative pleural effusions

Answer 1245

-empyema, malignancy, RA, esophageal rupture, pancreatitis, pulmonary infarction, TB

Question 1246

drug used to protect against infection w/ Mycobacterium avium complex in pts w/ a CD4 count

Answer 1246

Azithromycin

Question 1247

Once the HIV diagnosis is made, pts should be given the pneumococcal vaccine as soon as possible. They should receive it again in subsequent 5 year intervals. Tx w/ prophylactic abx is not usually indicated until the CD4 count is

Answer 1247

.

Question 1248

SVC syndrome

Answer 1248

- potential complication of lung malignancy, and is manifested by headache, facial swelling, and jugular venous engorgement without peripheral edema - the primary tx is radiation therapy as a palliative measure

Question 1249

conditions that predispose pts to the development of aspiration pneumonia

Answer 1249

- impaired consciousness (such as alcoholics, epileptics, or pts w/ a recent stroke) - the presence of tracheal or NG tubes - impaired gag reflex

Question 1250

Spontaneous bacterial peritonitis

Answer 1250

- common complication of ascites in which the peritoneal fluid becomes infected by an enteric organism that translocates across the intestinal wall - the finding on paracentesis of greater than 250 neutrophils/uL in the ascitic fluid is diagnostic

Question 1251

Bullous pemphigoid

Answer 1251

- autoimmune blistering disease that typically causes the formation of bullae in the flexural surfaces, groin, and axilla - biopsy of the lesion characteristically shows a subepidermal blister under light microscopy and linear Ig of basement membrane under immunofluorescence

Question 1252

Pemphigus vulgaris

Answer 1252

- autoimmune disease that causes INTRAepidermal blistering - usually have involvement of the oral cavity, and intact blisters are rare - tombstone appearance under light microscope

Question 1253

classic MRI findings of MS

Answer 1253

-ovoid plaques in the periventricular region, corpus collosum, and deep white matter

Question 1254

most common primary CNS tumor in adults

Answer 1254

glioma

Question 1255

Brain metastases

Answer 1255

- most common intracranial tumor in adults - most often due to melanoma, lung, breast, or renal cancer - appear as peripheral, circumscribed, enhancing lesions surrounded by vasogenic edema on MRI

Question 1256

Polymyalgia rheumatica

Answer 1256

-characterized by proximal muscle tenderness as opposed to weakness, and elevations of AST, ALT, and CPK are NOT typically seen

Question 1257

Polymyositis

Answer 1257

- symmetric, proximal muscle weakness along w/ the elevation of muscle enzymes, such as LDH and CPK - diagnosis can be confirmed using combination of autoantibody tests, EMG, and muscle biopsy

Question 1258

The presence of both UMN signs (hyperreflexia, Babinski sign) and LMN signs (fasciculations, atrophy) is typical of ALS. Nerve conduction studies, EMG, and neuroimaging can be obtained to exclude alternative diagnoses.

Answer 1258

.

Question 1259

Pts w/ complex partial seizures often stare blankly for several minutes and may engage in automatisms such as lip smacking or chewing. The presence of postictal confusion or paralysis (Todd's paralysis) helps distinguish complex partial seizures from other neurological disorders. Complex seizures involve a loss of consciousness (in contrast to simple seizures), and partial seizures involve seizure activity w/ a focal origin within the brain (in contrast to generalized seizures where seizure activity occurs globally throughout the cortex).

Answer 1259

.

Question 1260

does post-ictal confusion occur in Absence seizures?

Answer 1260

NO!

Question 1261

Both preterm labor and fetal lung immaturity have a higher incidence in diabetic mothers. Antenatal betamehasone can be given to promote fetal lung maturity, but the maternal blood glucose must be carefully followed.

Answer 1261

.

Question 1262

SLE

Answer 1262

- can cause an inflammatory arthritis that is usually migratory, polyarticular, and symmetric - the knees and hands are most commonly involved - the presence of other signs of SLE, such as renal disease and photosensitivity, can help to establish the diagnosis of lupus

Question 1263

Adenosine

Answer 1263

-used in the treatment of SUPRAventricular tachycardia (think of the den above the ventricles)

Question 1264

Digoxin

Answer 1264

-used in tx of SUPRAventricular tachyarrhythmias such as atrial fibrillation (think of digging oxygen to prevent atrial fibrillation, which is a common effect of hypoxemia)

Question 1265

Verapamil

Answer 1265

- used to treat SUPRAventricular tachycardia if adenosine is not effective in terminating the rhythm - NOT EFFECTIVE FOR VENTRICULAR TACHYCARDIA!!!!!

Question 1266

Wide-complex tachycardia

Answer 1266

- should be considered to be ventricular in origin unless its definitively interpreted as supraventricular tachycardia w/ aberrancy - in stable pts, tx consists of a loading dose of AMIODARONE ("aims at the down one" (ventricle))

Question 1267

brain metastases

Answer 1267

- most common intracranial tumor in adults - most often due to melanoma, lung, breast, or renal cancer, and appear as peripheral, circumscribed, enhancing lesions surrounded by vasogenic edema on MRI

Question 1268

Esophageal rupture usually leads to mediastinitis, which in turn can cause severe sepsis and death.

Answer 1268

.

Question 1269

Pancreatic calcifications and atrophy are frequently seen on abdominal CT in pts w/ chronic pancreatitis. Common clinical features include steatorrhea, abdominal pain, and diabetes mellitus. The most common cause of chronic pancreatitis is alcoholism.

Answer 1269

.

Question 1270

Tx for Wilson's disease

Answer 1270

Penicillamine (copper binder)

Question 1271

ABI

Answer 1271

- ratio of SYSTOLIC BP of ankle to SBP of brachial artery | - a normal ABI is 1.0-1.3; values between 0.4-0.9 suggest peripheral artery disease, and values

Question 1272

Tx for Guillain-Barre syndrome

Answer 1272

-IVIG

Question 1273

Primary hyperaldosteronism

Answer 1273

- most often due to bilateral adrenal hyperplasia or an aldosterone-producing adrenal adenoma - adrenalectomy is recommended for an adenoma, whereas aldosterone antagonists are recommended for bilateral hyperplasia - best test is early morning plasma aldosterone to renin ratio; elevated aldosterone (> 15 ng/dL) w/ a PAC/PRA ratio > 20 suggests PH - pts w/ PH should undergo CT of adrenal glands

Question 1274

Hypercalcemia of malignancy (HoM)

Answer 1274

- usually due to increased tumor production of parathyroid hormone-related peptide (PTHrP) - PTH levels are suppressed in pts w/ HoM - serum calcium levels are generally much higher in HoM than in primary hyperparathyroidism!

Question 1275

Pts who have had gastric bypass surgery have a higher incidence of developing gallstones due to an increase in bile concentration. Prophylactic tx w/ what is recommended to decrease this risk?

Answer 1275

Ursodeoxycholic acid

Question 1276

Hematuria can be due to glomerular or extraglomerular pathologies. Proteinuria suggests a glomerular cause. IgA nephropathy and post-strep glomerulonephritis are the 2 most common causes of glomerular hematuria in pts following a URI.

Answer 1276

.

Question 1277

an elevated phosphate level and a low calcium level in the setting of chronic kidney disease are characteristic of secondary hyperparathyroidism. The resulting elevation in parathyroid hormone can cause renal osteodystrophy w/ associated bone pain.

Answer 1277

.

Question 1278

ANCA antibodies

Answer 1278

-most frequently associated w/ small vessel vasculitides such as granulomatosis w/ polyangiitis (Wegener's)

Question 1279

anti-smooth muscle antibodies

Answer 1279

autoimmune hepatitis

Question 1280

anti-mitochondrial antibodies

Answer 1280

-primary biliary cirrhosis (PBC)

Question 1281

anti-centromere antibodies

Answer 1281

CREST syndrome

Question 1282

specific antibodies for SLE

Answer 1282

-anti-dsDNA and anti-smith antibodies

Question 1283

Visceral pain

Answer 1283

-usually more difficult to localize (eg generalized, crampy abdominal pain that pts experience w/ small bowel obstruction)

Question 1284

neuropathic pain

Answer 1284

pain secondary to destruction of nerve tissue itself, as in peripheral neuropathy -burning and tingling are common symptoms

Question 1285

causalgia

Answer 1285

-complex regional pain syndrome of the extremities characterized by swelling, pain, and bone demineralization often following minor trauma

Question 1286

somatic abdominal pain

Answer 1286

- well-localized, and is usually secondary to peritoneal irritation - in contrast, visceral pain is more vague in localization, and is usually the result of mechanical stretching of the abdominal viscera

Question 1287

SIADH

Answer 1287

- characterized by the inability of the kidneys to excrete water due to an abnormal amount of ADH - clinically, SIADH is suspected in a pt w/ hyponatremia, low serum osmolality, elevated urine osmolality, and elevated urine sodium

Question 1288

Muscarinic antagonists are used to treat urge incontinence (detrusor instability), the most common cause of urinary incontinence. Pts w/ detrusor instability experience intense urges to urinate that cannot be delayed.

Answer 1288

.

Question 1289

overflow incontinence

Answer 1289

- may result from a neurogenic bladder, and is treated w/ augmented voiding techniques and cholinergic agonists - more severe cases are treated w/ intermittent or indwelling bladder catheterization

Question 1290

Spontaneous bacterial peritonitis (SBP)

Answer 1290

- should be suspected in any patient w/ ascites and altered mental status - a diagnostic paracentesis that reveals more than 250 neutrophils/mm3 is diagnostic of SBP!!!! - initial tx consists of broad-spectrum antibiotics

Question 1291

Non-selective beta blockers such as propranolol or nadolol are often used to reduce the risk of esophageal variceal hemorrhage. Nitrates, endoscopic band ligation, and TIPS are other options that may be used to prevent variceal hemorrhage if B-blockers alone are ineffective.

Answer 1291

.

Question 1292

Myocarditis should be suspected in young pts w/ a recent viral illness who present w/ heart failure, chest pain, or arrhythmias. Most pts will have at least partial recovery of myocardial function, but some will develop dilated cardiomyopathy.

Answer 1292

.

Question 1293

Atopic dermatitis (eczema)

Answer 1293

- in adults, typically presents w/ an erythematous, scaly, pruritic rash - usually located on the flexural surfaces of the arms and knees as opposed to the extensor surfaces in psoriasis

Question 1294

nummular eczema

Answer 1294

-coin shaped, very pruritic patches of eczema that tend to involve the back and lower extremities

Question 1295

dyshidrotic eczema

Answer 1295

- form of dermatitis that involves the palms and soles | - tiny fluid filled blisters on palms and fingers

Question 1296

Pityriasis versicolor

Answer 1296

- skin infection caused by the YEAST, Malassezia furfur | - results in abnormally colored macules that are most commonly seen on the trunk and upper extremities

Question 1297

Painless jaundice

Answer 1297

- should be considered to be pancreatic cancer until proven otherwise - elevation of bilirubin and alk phos implies a cholestatic cause of jaundice, which can be caused by blockage of the common bile duct by a pancreatic mass

Question 1298

iron poisoning

Answer 1298

- causes GI hemorrhage, which is made evident by bloody diarrhea and hematemesis - severe poisoning may result in metabolic acidosis, hepatotoxicity, bowel obstruction, or death

Question 1299

CXR in pts w/ active TB

Answer 1299

-upper lobe infiltrate w/ cavitation and hilar lymphadenopathy

Question 1300

carotid sinus massage

Answer 1300

-can be both diagnostic and therapeutic for pts w/ SUPRAventricular tachycardia (SVT)

Question 1301

Hyperthyroidism should ALWAYS be considered in the evaluation of pts w/ atrial fibrillation, particularly if other signs or symptoms are present. TSH and free T4 are the appropriate initial diagnostic tests.

Answer 1301

.

Question 1302

new-onset seizures are a common presentation of brain tumors, the most common of which in adults are astrocytomas. The prognosis of astrocytomas is most affected by TUMOR GRADE, with increased atypia, mitoses, neovascularity, or necrosis conveying a worse prognosis.

Answer 1302

.

Question 1303

monoclonal antibodies directed against TNF-a

Answer 1303

-used to treat certain inflammatory diseases, such as RA or Crohn's disease

Question 1304

IL-1

Answer 1304

-cytokine that can be used to treat pts w/ RA

Question 1305

monoclonal antibodies directed against epidermal growth factor receptor (EGFR) (eg. cetuximab)

Answer 1305

-used in tx of various cancers including colorectal cancer

Question 1306

imatinib

Answer 1306

-inhibits BCR-ABL tyrosine kinase that is present in WBC of pts w/ CML!!!

Question 1307

CLL

Answer 1307

- occurs in elderly individuals - can be asymptomatic or have nonspecific symptoms such as fatigue, weight loss, or night sweats - may pts have a good prognosis even w/o tx, but treatment w/ a monoclonal antibody directed against the CD20 antigen on B lymphocytes may be used in symptomatic pts.

Question 1308

Infective endocarditis may be complicated by brain abscess through hematogenous seeding of bacteria or systemic embolization of vegetations. Pts may develop focal neuro deficits, evidence of elevated ICP, and fever. Diagnosis can be confirmed w/ gadolinium-enhanced brain MRI.

Answer 1308

.

Question 1309

Extrarenal fluid losses can result in hypovolemic hyponatremia due to secretion of ADH and retiention of free water. Pts have a decreased serum osmolality (normal is 285-295), decreased urine sodium concentration (

Answer 1309

.

Question 1310

Children w/ sickle cell disease are susceptible to splenic infarction, which predisposes them to infection w/ encapsulated organisms, particularly Strep pneumo. These pts should receive the pneumococcal vaccine and penicillin prophylaxis to lower the risk of serious pneumococcal infections.

Answer 1310

.

Question 1311

Pts w/ mitral valve prolapse (systolic murmur that prolongs w/ Valsalva due to decreased LV volume) have a slightly higher risk of developing infective endocarditis after certain invasive procedures than those w/ normal mitral valves. However, the 2007 AHA guidelines for the prevention of infective endocarditis do not recommend antimicrobial prophylaxis for pts w/ MVP, including those w/ mitral regurgitation!

Answer 1311

.

Question 1312

Dantrolene

Answer 1312

-muscle relaxant used in the tx of nueroleptic malignant syndrome, which refers to an idiosyncratic reaction to D2 antagonists characterized by fever, diffuse rigidity, mental status changes, and autonomic instability

Question 1313

Acute dystonia

Answer 1313

- type of extrapyramidal symptom and a common side effect of antipsychotic meds, particularly high-potency 1st generation antipsychotics (haloperidol) - tx consists of anticholinergic meds or diphenhydramine

Question 1314

ovarian cancer

Answer 1314

- should be in the differential diagnosis in any middle-aged woman w/ vague pelvic complaints, particularly if an adnexal mass is palpated - intraperitoneal spread is common in advanced cases

Question 1315

Small bowel obstruction

Answer 1315

- seen on plain radiography as dilatation of the small bowel greater than 3 cm w/ absence of air within the colon - most common cause of SBO in developed nations is adhesions from prior abdominal surgeries; next most common causes are indirect hernias or obstructing lesions

Question 1316

in aortic stenosis, there is increased blood velocity through the stenotic segment in order to keep blood flow relatively unchanged. This increased velocity may result in turbulence, which can be appreciated as a murmur on cardiac auscultation.

Answer 1316

.

Question 1317

recurrent attacks of epigastric or RUQ pain after eating w/ radiation to the right should or back is characteristic of gallstone disease. Risk factors for gallstone disease include obesity, female gender, age greater than 40, and pregnancy.

Answer 1317

.

Question 1318

bromocriptine

Answer 1318

-used to tx hyperprolactinemia caused by pituitary adenomas

Question 1319

pts w/ irregular menstrual periods, infertility, obesity, and hirsutism likely have PCOS. The best initial tx for resuming ovulation is weight loss, but clomiphene and/or metformin can be used if weight loss alone is ineffective.

Answer 1319

.

Question 1320

Episodic dizziness that occurs while rolling over in bed is a classic hx for benign paroxysmal positional vertigo (BPPV). The most effective tx for BPPV is repositioning the displaced otoliths w/ techniques such as the Epley maneuver.

Answer 1320

.

Question 1321

median nerve injury may occur w/ fractures that involve the supracondylar region of the humerus.

Answer 1321

.

Question 1322

frequent complication of humeral midshaft fractures

Answer 1322

- radial nerve injury | - results in weakness of the wrist and finger extensors as well as loss of sensation in the dorsum of the hand

Question 1323

If a metastatic pancreatic head carcinoma causes extrahepatic cholestasis due to common bile duct obstruction, then immediate tx should include endoscopic placement of a common bile duct stent.

Answer 1323

.

Question 1324

sickle cell vasoocclusive crisises

Answer 1324

- generally cause diffuse MSK pain - management involves pain control, hydration, and supplemental oxygen - sickle cell disease in general is more common in african americans and affected pts are usually chronically anemic

Question 1325

Quinidine

Answer 1325

-class 1 antiarrhythmic med that blocks sodium channels

Question 1326

clonidine

Answer 1326

-alpha-2-adrenergic agonist that functions as an anti-hypertensive agent by decreasing sympathetic outflow from the CNS

Question 1327

amlodipine

Answer 1327

-dihydropyridine calcium channel blocker that produces vasodilatation, thereby reducing BP

Question 1328

anticoagulation in addition to rate and/or rhythm control are the accepted tx's for atrial fibrillation. In the presence of tachycardia, beta-adrenergic antagonists (metoprolol or esmolol) or non-diphydropyridine (diltiazem, verapamil) CCBs can be used to rapidly control the heart rate.

Answer 1328

.

Question 1329

Mobitz type 1 (Wenckebach) second degree AV block

Answer 1329

-characterized by normal P waves and a PR interval that gradually increases w/ successive beats until a P wave fails to conduct to the ventricles, resulting in the absence of a QRS complex

Question 1330

atrial septal defect

Answer 1330

- characterized by wide, fixed splitting of the second heart sound on physical exam - a systolic murmur sometimes heard at the left upper sternal border from increased flow across the pulmonary valve, but there is usually not a murmur from the ASD itself

Question 1331

C. diff

Answer 1331

- most common cause of antibiotic-associated colitis - pts present w/ low grade fever, diarrhea, abdominal pain, and leukocytes in the stool - the most appropriate tx is oral metronidazole or oral vancomycin

Question 1332

Dementia w/ Lewy bodies

Answer 1332

- round, eosinophilic, and intracytoplasmic inclusions within the neurons of the substantia nigra - episodic fluctuating cognitive function (eg daytime drowsiness, daytime naps lasting > 2 hours, prolonged staring spells, episodes of disorganized speech), visual hallucinations, and parkinsonism

Question 1333

Septic shock should be suspected in pts w/ hemodynamic instability and evidence of an infection. The initial tx consists of IV fluids, followed by vasopressors such as dopamine or norepinephrine if the patient does not respond to fluid resuscitation.

Answer 1333

.

Question 1334

Urinary 5-HIAA excretion

Answer 1334

- measured as part of the work-up for possible carcinoid syndrome - affected pts present w/ diarrhea, abdominal cramping, flushing and telangiectasias

Question 1335

Parasitic infections present w/ diarrhea, abdominal pain, bloating, and eosinophilia. They are most common in pts living or traveling outside the US. The diagnosis is made through serial stool exams for ova and parasites.

Answer 1335

.

Question 1336

A patient w/ a combo of renal failure, hypercalcemia, and anemia?

Answer 1336

- evaluate for multiple myeloma - renal failure can occur in multiple myeloma from a variety of causes, but the most common is a toxic effect of light chain casts on the renal tubules - diagnosis is confirmed w/ serum protein electrophoresis (SPEP), urine protein electrophoresis (UPEP), bone marrow biopsy, and skeletal survey w/ plain radiographs to assess for lytic lesions.

Question 1337

self-destructive behavior

Answer 1337

Lesch-Nyhan syndrome

Question 1338

The presence of a fragile site in a segment of the X chromosome after cell culture in folate-deficient media is diagnostic of Fragile X syndrome. typical clinical features of this condition include autism spectrum behaviors, mental retardation, an elongated face, and large testes. Can also do molecular analysis of the number of CGG repeats in the FMR-1 gene on the X chromosome.

Answer 1338

.

Question 1339

Pts w/ chronic dementia are predisposed to delirium, which can be precipitated by acute infections or other medical stressors. If a patient becomes agitated to the point that they are endangering themselves, antipsychotic meds such as haloperidol are used as first-line therapy.

Answer 1339

.

Question 1340

Cervical cancer can potentially be prevented by Pap smear screening at age >21. Premenopausal women age >30 should undergo Pap smear and HPV testing. Those w/ a low-grade squamous intraepithelial lesion on Pap smear plus HPV 16 and 18 or unknown HPV status require further evaluation w/ colposcopy and biopsy.

Answer 1340

.

Question 1341

vulvovaginal candidiasis

Answer 1341

- causes inflammation of the vulva and vagina, resulting in erythema and pruritis - it can be distinguished from other causes of vaginitis by a normal vaginal pH of 3.8 - 4.2

Question 1342

Pts w/ 3 alpha globin chain mutations

Answer 1342

- (a,-)(-,-) - hemoglobin H disease (composed of 4 beta chains) - severe microcytic, hypochromic anemia w/ target cells and Heinz bodies as well as hepatosplenomegaly

Question 1343

alpha thalassemia minima

Answer 1343

- characterized by one alpha globin gene mutation (a,a)(a,-) | - pts typically have no clinical or lab abnormalities

Question 1344

mutations in all 4 alpha globin genes (-,-)(-,-)

Answer 1344

- hydrops fetalis - most severe form of alpha thalassemia - not compatible with life

Question 1345

heterozygous alpha thalassemia minor

Answer 1345

- typically asymptomatic although pts may complain of mild fatigability - affected pts will have mild hypochromic anemia, severe microcytosis, and target cells - may be cis (a,a)(-,-) or trans (a,-)(a,-)

Question 1346

Hemiparalysis w/ abnormal function of a contralateral cranial nerve is sometimes referred to as crossed paralysis, and localizes a particular lesion to the brainstem. In the case of hemiparalysis w/ contralateral facial weakness, the lesion is most likely located in the facial nerve nucleus in the pons.

Answer 1346

.

Question 1347

The initial medical work-up of new-onset psychiatric symptoms often includes head CT scan, CBC, thyroid function tests, syphilis screen, metabolic panel, and urine toxicology

Answer 1347

.

Question 1348

Ventricular septum rupture is a complication that can occur 3-5 days after an MI. Pts present w/ acute hemodynamic compromise and a holosystolic murmur at the left sternal border. Cardiac catheterization may show an influx of oxygenated blood from the left ventricle into the right ventricle, as well as an increase in right-sided heart pressures from increased flow.

Answer 1348

.

Question 1349

cardiac tamponade classically causes equilibration of diastolic pressures on cardiac catheterization.

Answer 1349

.

Question 1350

PE should be considered in pts w/ hypoxia, tachypnea, and tachycardia. On cardiac catheterization, right heart pressures are elevated, as is the gradient between the pulmonary artery and the PCWP.

Answer 1350

.

Question 1351

normal pulmonary capillary wedge pressure?

Answer 1351

6-12 mmHg | -provides indirect estimate of left atrial pressure

Question 1352

Mitral stenosis

Answer 1352

- characterized by a low-pitched diastolic murmur heard best at the apex - occurs earlier in diastole w/ worsening stenosis, and can become holodiastolic in pts w/ severe stenosis

Question 1353

cervical cancer screening

Answer 1353

- immunocompromised: onset of sexual intercourse; every 6 months x 2 then annually - age 65: no screening if negative prior screens and not high risk for cervical cancer - hysterectomy (w/ cervix removed): no screening if no hx of high-grade precancerous lesion, cervical cancer, or exposure to diethylstilbestrol

Question 1354

sreening mammography is recommended every 2 years for women age > 50 as it can diagnose early asymptomatic breast cancer and improve mortality among screened pts. Other recommendations include monitoring lipid profile every 5 years and colon cancer screening (eg colonoscopy every 10 yrs). Cervical cancer screening can be discontinued in women > age 65 w/ previously normal results and low cervical cancer risk.

Answer 1354

.

Question 1355

a systolic murmur heard best at the left sternal border that decreases in intensity w/ increased preload

Answer 1355

- characteristic of hypertrophic cardiomyopathy | - common in young pts who present w/ syncope, and is important to diagnose because it can lead to sudden cardiac death

Question 1356

Pain relief w/ elevation of the testicle?

Answer 1356

Epididymitis

Question 1357

the acute onset of testicular pain in a teenage male should be considered testicular torsion until proven otherwise, and is a potential surgical emergency. The cremasteric reflex is almost always absent in testicular torsion and Prehn's sign (pain relief w/ evelation of the testicle) will be NEGATIVE, differentiating it from epididymitis.

Answer 1357

.

Question 1358

common adverse effects associated w/ cisplatin?

Answer 1358

-nephrotoxicity, tinnitus and hearing loss, electrolyte abnormalities, severe nausea and vomiting, and neurotoxicity

Question 1359

Findings for nephrotic syndrome

Answer 1359

- urine protein excretion of > 3.5g/day, edema, and hypoalbuminemia - FSGS is the most common cause of NS in adults, particularly african americans

Question 1360

pulmonary contusions

Answer 1360

-common consequence of thoracic trauma that generally manifest over the course of the first day w/ an airspace opacity on CXR and findings consistent w/ alveolar fluid on physical exam

Question 1361

Lennox-Gastaut syndrome

Answer 1361

-typically diagnosed in children under the age of 7 who have a wide array of seizure types accompanied by mental retardation

Question 1362

Juvenile myoclonic epilepsy

Answer 1362

- usually present in their teenage years w/ a progression from absence to myoclonic to generalized tonic-clonic seizures - the seizures typically occur upon awakening - JME is genetic, and symptoms can be worsened w/ sleep deprivation

Question 1363

Cushing's syndrome

Answer 1363

- presents w/ central obesity, proximal muscle weakness, androgen excess, menstrual irregularities, HTN, and easy bruising - in the absence of exogenous glucocorticoid administration, the most common etiologies of Cushing's syndrome include increased pituitary secretion of ACTH (Cushing's disease), an adrenal tumor, and ectopic ACTH production

Question 1364

Venodilation decreases the pain associated w/ acute MI by reducing preload, which leads to a reduction in myocardial oxygen demand. This effect is most commonly caused by the use of organic nitrates in the setting of acute MI

Answer 1364

.

Question 1365

Intestinal malrotation and midgut volvulus

Answer 1365

- should be suspected in any neonate w/ bilious vomiting - rapid evaluation and surgical tx is required as bowel necrosis can develop quickly - the classic finding on upper GI series is a corkscrew-shaped duodenum that is abnormally located in the right abdomen

Question 1366

tx for cryptococcal meningitis

Answer 1366

combination of amphotericin B and flucytosine | -subacute presentation

Question 1367

TREATMENT of toxoplasmosis

Answer 1367

-pyrimethamine and sulfadiazine (NOT TMP-SMX!!!! This is for prophylaxis!!)

Question 1368

Listeria monocytogenes

Answer 1368

- important cause of meningitis in adults over the age of 60 and in immunocompromised pts - AMPICILLIN should be added to the empiric abx regimen of ceftriaxone and vancomycin in these pts

Question 1369

oral colchicine

Answer 1369

treats ACUTE gouty arthritis

Question 1370

Febuxostat, allopurinol, probenecid

Answer 1370

- febuxostat and allopurinol are xanthine oxidase inhibitors that decrease uric acid production - allopurinol is usually preferred, and febuxostat is reserved for pts who cannot tolerate allopurinol - probenecid is a uricosuric med that increases uric acid excretion in the kidneys

Question 1371

lifestyle modifications, including alcohol cessation and weight loss, are considered first-line interventions following an initial gout attack. Meds for lowering serum urate are indicated for pts w/ repeated and disabling attacks of gouty arthritis, tophi, x-ray evidence of chronic gouty joint disease, uric acid kidney stones, or renal insufficiency

Answer 1371

.

Question 1372

an apical lung tumor in the thoracic inlet can compress the cervical and thoracic nerve roots that contribute to the ulnar nerve, resulting in pain, numbness and weakness in the ipsilateral arm.

Answer 1372

.

Question 1373

a diastolic decrescend murmur heard best at the left sternal border

Answer 1373

- aortic regurgitation | - most common cause in an elderly patient w/ atherosclerotic risk factors is aortic root dilation

Question 1374

Guillain-Barre syndrome

Answer 1374

- typically presents w/ symmetric, ascending weakness and loss of reflexes w/ relative preservation of sensory function - it is often associated w/ a preceding respiratory or GI infection - the classic finding on LP in pts w/ GBS is an elevated protein content w/ a normal WBC count, referred to as ALBUMINOCYTOLOGIC DISSOCIATION

Question 1375

somatic symptom disorder

Answer 1375

-excessive anxiety and preoccupation with 1 or more unexplained symptoms

Question 1376

illness anxiety disorder

Answer 1376

-fear of having a serious illness despite few or no symptoms and consistently negative evaluations

Question 1377

conversion disorder (functional neruologic symptom disorder)

Answer 1377

-neurologic symptom incompatible w/ any known neurologic diseas; often acute onset associated w/ stress

Question 1378

factitious disorder

Answer 1378

-intentional falsification or inducement of symptoms w/ goal to assume SICK ROLE

Question 1379

malingering

Answer 1379

-falsification or exaggeration of symptoms to obtain external incentives (SECONDARY GAIN)

Question 1380

most cases of pediatric pharyngitis are the result of self-limiting viral infections. No treatment or further workup is required when cough, runny nose, and oral vesicles are present.

Answer 1380

.

Question 1381

Churg-Strauss syndrome

Answer 1381

- eosinophilic vasculitis | - may present w/ renal and upper airway symptoms, but asthma and eosinophillia are present in nearly all pts

Question 1382

Granulomatosis w/ polyangiitis (Wegener's)

Answer 1382

- form of granulomatous vasculitis that typically presents w/ involvement of the upper airways, lungs, and kidneys - diagnosis can be confirmed w/ serum ANCA testing or by finding granulomatous inflammation on biopsy of upper airway lesions

Question 1383

Myelodysplastic syndrome (MDS)

Answer 1383

- hematologic disorder that is more common in pts over 65 yrs old and usually presents w/ macrocytic anemia, leukopenia, and thrombocytopenia - ovalo-macrocytes are commonly seen on a peripheral smear along w/ neutrophils w/ decreased segmentation, as opposed to the megaloblastic, hypersegmented neutrophils seen in pts w/ B12 or folate deficiency

Question 1384

atropine

Answer 1384

-used in the treatment of severe bradycardia

Question 1385

initial tx of pheochromocytoma

Answer 1385

-first, a-blockade w/ a med such as phenoxybenzamine followed by the use of b-blockers, after which surgery should be performed

Question 1386

impetigo

Answer 1386

- presents as an erythematous skin lesion covered w/ a golden crust, and is typically seen on the face or upper extremities - S. aureus and group A strep are the most common etiologies - pts who have group A strep impetigo are at risk of developing post-strep glomerulonephritis

Question 1387

COPD exacerbations

Answer 1387

- should be diagnosed when a patient w/ underlying COPD presents w/ increased SOB, cough, or sputum production - systemic glucocorticoids should be given to pts w a COPD exacerbation because they have been shown to improve lung function and promote a shorter hospital stay

Question 1388

tumor lysis syndrome

Answer 1388

-marked by hypocalcemia, hyperphosphatemia, hyperkalemia, and elevated uric acid levels causing nausea and vomiting, bowel disturbances, low urine output, acute renal insufficiency, seizures, tetany, and/or arrhythmias

Question 1389

Chemotherapy can cause neutropenia, putting pts at increased risk for systemic infections and sepsis. Neutropenic pts do not mount a normal immune response to infection, thus, signs and symptoms of sepsis may be subtler than in an immunocompetent patient.

Answer 1389

.

Question 1390

do NOT use topical abx on infected diabetic ulcers, debride instead and use oral or IV abx

Answer 1390

.

Question 1391

foot ulcers

Answer 1391

- very common in diabetic pts due to a combination of peripheral neuropathy and peripheral vascular disease - important factors in evaluating foot ulcers include the depth of involvement and the presence of infection - if there is no infection and the ulcer does not involve the bone, debridement of the necrotic tissue is usually sufficient tx

Question 1392

mood stabilizers, including lithium, lamotrigine, and valproic acid, are first-line maintenance treatments for bipolar disorder, w/ efficacy in bipolar depression w/ mixed features.

Answer 1392

.

Question 1393

Irregular menstrual periods, infertility, and galactorrhea are typical findings in hyperprolactinemia. It's commonly caused by a prolactin secreting pituitary adenoma, which can be treated w/ dopamine agonists to decrease the secretion of prolactin as well as to decrease the size of the tumor.

Answer 1393

.

Question 1394

observer bias

Answer 1394

-type of measurement bias in which the investigator unconsciously influences the outcome of the study by knowing the exposure status of each participant

Question 1395

The Hawthorne effect

Answer 1395

-refers to a change in behavior that occurs if the participants know they are being studied

Question 1396

ascertainment bias

Answer 1396

-occurs when the results from an atypical population are extrapolated into the entire population

Question 1397

if a patient's treatment regimen is selected based upon the severity of their condition, they may have a worse outcome because of selection bias and not necessarily due to the treatment itself.

Answer 1397

.

Question 1398

brief psychotic disorder

Answer 1398

-characterized by sudden onset of psychotic symptoms (delusions, hallucinations, disorganized speech/behavior) lasting at least 1 day and less than 1 month

Question 1399

schizoid personality disorder

Answer 1399

-characterized by a lifelong pattern of detachment from social relationships and restricted range of emotions

Question 1400

schizophreniform disorder

Answer 1400

-characterized by psychotic symptoms that last 1-6 months

Question 1401

schizotypal personality disorder

Answer 1401

-pts are typically "odd", holding magical beliefs and strange (but not overtly psychotic) though processes

Question 1402

borderline personality disorder

Answer 1402

- involves a pervasive pattern of impulsivity, mood instability, and an unstable sense of self - associated characteristics include fear of abandonment and unstable chaotic relationships - transient paranoia and psychosis may occur and last minutes to hours; these have been termed "micropsychotic episodes"

Question 1403

new-onset psychosis in a patient w/ active medical problems requires a workup to determine the medical cause. Pts w/ hypothyroidism are commonly diagnosed w/ depression and can also experience psychotic symptoms in severe cases.

Answer 1403

.

Question 1404

type 2 renal tubular acidosis

Answer 1404

-impaired bicarb reabsorption in the proximal renal tubules, which causes a non-anion gap metabolic acidosis

Question 1405

impaired urine acidification in the distal renal tubules

Answer 1405

type 1 renal tubular acidosis, which causes a non-anion gap metabolic acidosis

Question 1406

DKA

Answer 1406

- presents w/ polyuria, polydipsia, abdominal pain, vomiting, and metabolic acidosis - low serum bicarb, elevated anion gap, and hyperglycemia are diagnostic of the condition - lack of insulin causes breakdown of fatty acids to ketones in the liver, which leads to acidosis and the clinical manifestations of DKA

Question 1407

Tx of DKA

Answer 1407

- consists of gradual fluid resuscitation w/ a 10 mL/kg bolus of normal saline over 1 hour; this should be followed by an IV insulin drip w/ isotonic fluids containing potassium - the patient can be transitioned to a subcutaneous insulin regimen when the anion gap closes and the metabolic acidosis resolves

Question 1408

An elderly patient with lymphadenopathy and lymphocytosis likely has chronic lymphocytic leukemia (CLL). Smudge cells, which represent fragile but mature lymphocytes, may be seen on peripheral blood smear.

Answer 1408

.

Question 1409

Atelectasis is often seen in pts w/ post-op fever, but it has been shown that atelectasis by itself is not the cause of fever. This is a common misconception, and post-op fever should not be ascribed to atelectasis.

Answer 1409

.

Question 1410

Spherocytes are small, hyperchromic red cells without central pallor. Spherocytosis can be inherited or acquired. Affected pts are prone to bilirubin gallstones as a complication of chronic hemolysis.

Answer 1410

.

Question 1411

side effects of abacavir

Answer 1411

-lactic acidosis, hepatitis, hypersensitivity reaction

Question 1412

side effect of didanosine

Answer 1412

pancreatitis

Question 1413

side effects of Efavirenz?

Answer 1413

non-nucleoside reverse transcriptase inhibitor known to cause insomnia with vivid, bizarre dreams

Question 1414

urge incontinence

Answer 1414

- refers to an involuntary leakage of urine accompanied by a sensation of urgency - initial tx are conservative, consisting of bladder training and establishing a voiding schedule

Question 1415

Kawasaki disease

Answer 1415

-childhood vasculitis that typically consists of fever, conjunctival injection, oral mucous membrane changes, erythema or edema of the palms and soles, polymorphous rash, and cervical lymphadenopathy

Question 1416

Henoch-Schonlein Purpura

Answer 1416

- childhood illness w/ pathologic findings of leukocytoclastic vasculitis w/ IgA deposition - clinical findings include palpable purpura, abdominal pain, renal failure, and arthralgia

Question 1417

the most important conditions to consider in pts w/ third trimester bleeding are placenta previa and placental abruption. Placenta previa typically causes PAINLESS vaginal bleeding, while abruption is usually PAINFUL. Diagnosis can be made w/ TRANSABDOMINAL US, and vaginal exam should be WITHHELD until placenta previa has been excluded by US.

Answer 1417

.

Question 1418

Patients may have blunt chest trauma-related injury to the great vessels while remaining hemodynamically stable w/ few chest-related complaints. The finding of a widened mediastinum on chest x-ray requires further work-up w/ TEE or CT scanning.

Answer 1418

.

Question 1419

Bartholin's gland abscess

Answer 1419

- can cause pain w/ walking, sitting, and sexual intercourse - exam reveals a tender mass in the medial aspect of the labia majora at either the 4 or 8 o'clock position - as with any abscess, incision and drainage is the most appropriate therapy

Question 1420

The inability to extend the knee more than 135 degrees while the hip is flexed is known as Kernig's sign, and it is suggestive of meningeal irritation from meningitis.

Answer 1420

.

Question 1421

migraine therapies

Answer 1421

- abortives: triptans, NSAIDs, acetaminophen, antiemetics, ergots - preventatives: topiramate, divalproex sodium, TCAs, beta-blockers

Question 1422

Coadministration of a triptan and ergotamine may result in prolonged vasospasm due to overactivation of serotonin (5-HT) receptors. Therefore, triptans should not be given for at least 24 hrs after ergotamine is given and vice-versa.

Answer 1422

.

Question 1423

Kawasaki disease

Answer 1423

- associated w/ the development of coronary artery aneurysms - tx w/ IVIG and aspirin helps decrease the risk of coronary complicaitons - diganosis: fever for 5 or more days, along w/ 4 or more of the following: oral mucous membranes changes (strawberry tongue, cracked lips), bilateral nonexudative conjunctivitis w/ limbal sparing, cervical lymphadenopathy (> 1.5 cm), polymorphous rash, erythema or edema of the hands and feet

Question 1424

tx for rocky mountain spotted fever?

Answer 1424

doxycycline

Question 1425

Koplik spots

Answer 1425

-small white spots on buccal mucosa seen in measles

Question 1426

Forschheimer spots

Answer 1426

-petechiae on soft palate seen in rubella

Question 1427

Primary open angle glaucoma

Answer 1427

- increased IOP | - presents w/ progressive loss of vision in the peripheral visual fields followed by central visual loss

Question 1428

macular degeneration

Answer 1428

-caused by pigment accumulation in the retina, which typically presents w/ central visual loss

Question 1429

cataracts

Answer 1429

- characterized by painless loss of vision that is worse at night; classically described as "glare" while driving at night - surgical tx is required

Question 1430

most pts who have had a splenectomy will have thrombocytosis because one of the spleen's functions is to remove old platelets from the circulation.

Answer 1430

.

Question 1431

Infection w/ Chlamydia trachomatis

Answer 1431

- should be suspected in any young pt w/ dysuria, cervical friability, or vaginal discharge, esp. if the Gram stain of the discharge shows numerous neutrophils w/o any organisms - chlamydial infection can lead to the development of PID if untreated, which can eventually cause infertility

Question 1432

amiodarone

Answer 1432

-antiarrhythmic used to manage VENTRICULAR arrhythmias in pts w/ heart failure and/or systolic LV dysfunction

Question 1433

Digoxin

Answer 1433

- adjunctive therapy for symptom control in pts w/ heart failure and LV systolic dysfunction - reduces the rate of hospitalization for heart failure but has not been shown to improve overall survival

Question 1434

Medications that improve long-term SURVIVAL in pts w/ LV systolic dysfunction (EF

Answer 1434

- ACE-I - ARBs - beta-blockers (metoprolol, carvedilol, bisoprolol) - aldosterone angatgonists - combo of hydralazine and nitrates in blacks

Question 1435

Hypothyroidism can cause a variety of menstrual abnormalities, including amenorrhea, irregular menses, and menorrhagia. It can also cause hyperprolactinemia w/ associated galactorrhea due to TRH stimulation of lactotrophs.

Answer 1435

.

Question 1436

mechanism of carpal tunnel syndrome in pregnancy vs. hypothyroidism

Answer 1436

- in pregnancy: fluid accumulation within the carpal tunnel - in hypothyroidism: accumulation of matrix substances (mucin, mucopolysaccharide) within both the perineurium as well as tendons

Question 1437

tocolytics

Answer 1437

-calcium channel blockers (eg nifedipine), b-agonists (terbutaline, ritodrine), and cyclooxygenase inhibitors (eg indomethacin; only between 24-32 wks though)

Question 1438

magnesium sulfate in pregnancy

Answer 1438

-used for fetal neuroprotection in preterm births

Question 1439

Pulmonary edema should be considered in any patient with rapid-onset hypoxia, tachypnea, and bibasilar crackles. B-agonists are first-line tocolytics that can cause pulmonary edema.

Answer 1439

.

Question 1440

Cyanosis in highly vascularized tissues such as the lips and mucous membranes is consistent w/ CENTRAL CYANOSIS, as opposed to PERIPHERAL CYANOSIS which usually only involves the distal extremities. Central cyanosis is caused by low arterial oxygen saturation, whereas peripheral cyanosis is due to increased oxygen extraction secondary to sluggish blood flow.

Answer 1440

.

Question 1441

Pts w/ familial dysbetalipoproteinema (Frederickson Type III Hyperlipidemia)

Answer 1441

- develop hypertriglyceridemia - a classic clinical finding is striate palmar xanthomas - the most appropriate initial tx is w/ a fibric acid derivative (eg fenofibrate)

Question 1442

preterm labor

Answer 1442

-regular contractions occurring before 37 wks gestation associated w/ cervical changes

Question 1443

women w/ advanced cervical dilation in the absence of labor and abruption are candidates for cervical cerclage. If a woman is in labor, cervical cerclage is contraindicated.

Answer 1443

.

Question 1444

All women who are at risk for preterm delivery between 24 and 34 weeks of gestation are candidates for corticosteroid therapy to enhance fetal lung maturity and decrease neonatal morbidity.

Answer 1444

.

Question 1445

Sulfonylureas

Answer 1445

-act on pancreas to increase endogenous insulin production

Question 1446

metformin and the thiazolidinediones (TZDs)

Answer 1446

-both increase the insulin sensitivity of peripheral tissues

Question 1447

the most effective tx in slowing the progression of diabetic nephropathy?

Answer 1447

-maintaining a BP of less than 130/80, particularly w/ ACE-I or ARBs

Question 1448

Ulnar nerve compression

Answer 1448

- usually occurs at the elbow, either in the epicondylar groove or the cubital tunnel - repetitive flexion and extension of the elbow, often secondary to occupational stress, may lead to compression in the cubital canal - typical symptoms include paresthesias in the 4th and 5th fingers as well as the medial forearm in addition to weakness of the intrinsic hand muscles

Question 1449

hand-foot-mouth disease and herpangina organism?

Answer 1449

Coxsackie virus

Question 1450

common skin infections caused by Strep pyogenes?

Answer 1450

- non-purulent cellulitis - impetigo (nonbullous) - scarlet fever (confluent erythematous rash preceded by strep pharyngitis) - erysipelas (raised, demarcated dermal inflammation/tenderness/warmth)

Question 1451

Roseola infantum

Answer 1451

- viral infection caused by human herpesvirus 6 | - characterized by 3-5 days of a very high fever followed by a rose-colored maculopapular exanthem

Question 1452

Raynaud phenomenon

Answer 1452

- cold induced vasospasm typically seen in the fingers, and is more common in pts w/ connective tissue disorders such as scleroderma - tx consists of CCBs such as nifedipine

Question 1453

long-term use of combination oral contraceptives increases the risk of which cancers, and decreases the risk of which cancers?

Answer 1453

- increases risk: breast and cervical (returns to normal within 10 yrs of dc) - decreases risk: endometrial and ovarian

Question 1454

pts w/ TTP usually have changes in their mental status as well as renal insufficiency!

Answer 1454

.

Question 1455

Heparin-induced thrombocytopenia (HIT)

Answer 1455

- should be suspected in pts w/ thrombocytopenia after a recent hx of heparin exposure - despite the low platelet count, most of the complications of HIT occur from thrombosis - therefore, tx w/ alternative anticoagulants is required after stopping all heparin containing therapies - do NOT give platelet transfusions!! may worsen hypercoagulability

Question 1456

Severe hypercalcemia

Answer 1456

- can lead to an altered mental status, and is sometimes seen in pts w/ squamous cell carcinoma of the lung due to the secretion of parathyroid hormone-related peptide (PTHrP) - pts w/ severe hypercalcemia are typically volume depleted, and as a result, initial therapy should consist primarily of fluid resuscitation w/ isotonic saline

Question 1457

endometriosis

Answer 1457

- common cause of infertility and cyclic pelvic pain in young females - possible findings on exam include pain or nodularity of the rectovaginal septum as well as fixation of the uterus in a retroverted position - diagnosis usually requires laparoscopy, but a pelvic US can sometimes be helpful in localizing a large endometrioma

Question 1458

Pts w/ a subarachnoid hemorrhage typically complain of a severe headache of abrupt onset. A non-contrast CT scan of the head should be obtained in any patient in whom SAH is suspected.

Answer 1458

.

Question 1459

Arrhythmia should be suspected as the cause of a patient's syncope if there is a hx of rapid-onset loss of consciousness w/o a preceding prodrome. Usage of anti-arrhythmic drugs, structural heart disease, and hypokalemia and/or hypomagnesemia are all potential predisposing factors for torsades de pointes.

Answer 1459

.

Question 1460

Lidocaine

Answer 1460

-may be used in the tx of ventricular arrhythmias, other than torsades de pointes

Question 1461

adenosine

Answer 1461

-may be used in tx of SUPRAventricular tachycardia

Question 1462

digoxin

Answer 1462

-may be used for the tx of heart failure or as a rate control agent in atrial fibrillation

Question 1463

verapamil

Answer 1463

-CCB used for rate control in SUPRAventricular tachycardias

Question 1464

Amiodarone

Answer 1464

-used in tx of ventricular and atrial arrhythmias

Question 1465

Certain antiarrhythmic meds, structural heart disease, and hypokalemia and hypomagnesemia can predispose to QT interval prolongation and possible development of torsades de pointes. The initial tx of torsades in pts who are hemodynamically STABLE is magnesium sulfate, even if the pts magnesium level is normal.

Answer 1465

.

Question 1466

Amaurosis fugax

Answer 1466

-sudden, painless, transient monocular vision loss that most commonly results from retinal artery emboli originating from a carotid artery atherosclerotic plaque

Question 1467

Optic neuritis in MS can cause transient monocular visual disturbances or blindness, typically associated w/ other neurologic symptoms characteristic of MS

Answer 1467

.

Question 1468

fibroadenomas

Answer 1468

- seen in young women as a firm, rubbery mass that moves easily w/ palpation - either FNA or sonogram can establish diagnosis - removal is optional

Question 1469

giant juvenile fibroadenomas

Answer 1469

- seen in very young adolescents, where they have very rapid growth - removal is needed to avoid deformity and distortion of the breast

Question 1470

cystosarcoma phyllodes

Answer 1470

- senn in late 20s - breast mass that grow over many years, becoming very large, replacing and distorting the entire breast, yet no invading or becoming fixed - most are benign, but they have malignant potential - core or incisional biopsy is needed (FNA is NOT sufficient), and removal is MANDATORY

Question 1471

mammary dysplasia (fibrocystic disease)

Answer 1471

- seen in 30s and 40s, w/ bilateral tenderness related to menstrual cycles (worse in last 2 weeks) and multiple lumps that seem to come and go (they are cysts) - persistent mass requires aspiration, if clear fluid and mass goes away, that's it; if mass persists, formal biopsy required

Question 1472

intraductal papilloma

Answer 1472

- seen in young women (20s to 40s) w/ BLOODY NIPPLE DISCHARGE - mammogram is needed to identify other potential lesions, but will not show papilloma - galactogram may be diagnostic and guides surgical resection

Question 1473

breast abscess

Answer 1473

- seen only in lactating women | - I&D is needed, but biopsy of the abscess wall should be done also

Question 1474

breast cancer

Answer 1474

- should be suspected in any woman w/ a palpable breast mass - other indicators: ill-defined fixed mass, retraction of overlying skin, "orange peel" skin, recent retraction of nipple, eczematoid lesion of the areola, reddish orange peel skin over mass (INFLAMMATORY breast cancer), and palpable axillary nodes - note that a hx of trauma does NOT rule out cancer!!

Question 1475

breast cancer during pregnancy

Answer 1475

- diagnosed exactly as if pregnancy did not exist and is treated the same way except for: no radiotherapy during ENTIRE pregnancy, and no chemo during the FIRST TRIMESTER - termination of the pregnancy is not necessary

Question 1476

infiltrating ductal carcinoma

Answer 1476

- standard form of breast cancer - INFLAMMATORY cancer is the only variant w/ much worse prognosis (and the need for pre-op chemo) - other variants (lobular, medullary, mucinous) have slightly better prognosis and are treated the same way as the standard infiltrating ductal - lobular has higher incidence of bilaterality

Question 1477

ductal carcinoma in situ

Answer 1477

- cannot metastasize (thus no axillary sampling is needed), but has very high incidence of recurrence if only local excision is done - total simple mastectomy is recommended for multicentric lesions throughout the breast - lumpectomy followed by radiation is used if the lesion is confined to 1/4 of the breast

Question 1478

inoperability of breast cancer is based on LOCAL EXTENT (not metastases)

Answer 1478

.

Question 1479

abx that treat pseudomonas

Answer 1479

- cefTAZidime (3rd gen) - cefePIME (4th gen) - aminoglycosides (gentamicin, amikacin, streptomycin, tobramycin, etc.) - ticarcillin - aztreonam - carbapenems - ciprofloxacin

Question 1480

conductive vs sensorineural hearing loss

Answer 1480

Rinne test results: -Normal hearing will show an air-conduction time that is twice as long as the bone conduction -If a patient has conductive hearing loss, the bone conduction sound is longer than or equal to the air conduction sound. -If a patient has sensorineural hearing loss, air conduction is heard longer than bone conduction, but it is not heard to be twice as long. Weber Test Results: -Normal hearing will indicate sound in both ears. -Conductive loss will indicate the sound travels towards the poor ear. -Sensorineural loss will indicate the sound travels towards the good ear