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1
Q

define adenomyosis

A

endometrial glands trapped in myometrium

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2
Q

adenomyosis
presentation
physical exam

A

female ^40 yo
dysmenorrhea w
heavy menstrual bleeding
progression to chronic pelvic pain

boggy tender uniformly enlarged uterus

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3
Q

define heavy menstrual bleeding

A

soaking a pad or

changing tampon q2h

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4
Q

synonymns for boggy

A

soft

flaccid

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5
Q

adenomyosis
dx
tx

A

pelvic us and/or mri initially
bx amd histopath definitively

ocp, levonorgestrel iud
hysterectomy if these unsuccessful

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6
Q

levonorgestrel moa

A

thickens cervical mucus against sperm
inhib ovulation
inhib fsh and lh
alters endometrium against implantation

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7
Q

bladder pain syndrom aka

A

interstitial cystitis

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8
Q

bladder pain syndrome

A

pain over anterior vaginal wall
discomfort w bladder filling
dysuria
urinary freq

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9
Q

is post coital bleeding from cervical cancer assoc w pain?

A

no

painless

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10
Q

fibroids aka

A

uterine leiomyomata

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11
Q

tf

depression often presents to pcp with physical complaints such ad headaches, aches and pains, insomnia, fatigue

A

t

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12
Q

explain weight loss in cancer

A

v po intake
systemic inflammation ~ hypercatabolism

CACS
cancer-related anorexia cachexia syndrome

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13
Q

treat CACS

cancer-related anorexia cachexia syndrome

A

progesterone analogue
(megestrol acetate)
if longer life expectancy

can consider corticosteroid if shorter expectancy (more SEs)

  • stim apetite, weight gain, possibly assoc w some antiinflammation
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14
Q

tf

dronabinol tx CACS cancer-related anorexia cachexia

A

f
some clinical effectiveness for HIV cachexia

not cancer cachexia – use megestrol acetate or corticosteroid if short expectancy

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15
Q

tf

nutritional education amd supplementation iv or po is effective for tx of cacs cancer-associated anorexia cachexia

A

f
not very effective.
megestrol acetate long expect (progesterone analogue)
or corticosteroids short expectancy (more SE’s)

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16
Q

child refusal to speak in certain situations for more than a month, but normal interactions in other situations

A

selective mutism

a social anxiety disorder

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17
Q

at what age does stranger anxiety typically begin and end

A

6mos - 3yrs

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18
Q

tf

selective mutism does not need to be treated

A

f

treat early to avoid education and social impairment

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19
Q

sympx w blood loss of
100ml 20%
150ml 30%
200ml 40%

A
  • orthostasis hr100+ rr20+ agitation cool
  • hypotension hr120+ rr30+ confusion cool
  • severe hypotension hr140+ rr40+ obtunded cold
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20
Q

hyper igM aka

A

cd40 ligamd deficiency

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21
Q

cd40 liganf deficiency aka

A

hyper igM

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22
Q

normal b cell count
high igM
low igGAE
dx

A

hyper igM

aka cd40 ligand deficiency

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23
Q

normal b cell count
low igMGAE
dx

A

common variable immunodeficiency

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24
Q

common variable immunodeficiency
b cell count
and ig quantities

A

normal b cell count

low igMGAE

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25
Q

job synndrome aka

A

hyper igE

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26
Q

hyper igE aka

A

job syndrome

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27
Q

normal b cell count
high igE but other igs normal
dx

A

hyper igE

job syndrome

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28
Q

nl b cell count
nl igMGE
low igA
dx

A

selective igA deficiency

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29
Q

low b cell count
low igMGAE
dx

A

x-linked agammaglobulinemia
aka
bruton agammaglobulinemia

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30
Q

how to calc b cell count from total lymphos and t lymphos

A

subtract that shit

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31
Q

bruton agammaglobulinemia

aka

A

x linked agammaglobulinemia

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32
Q

bruton x linked agammaglobulinemia
pathogenesis
sympx
tx

A

tk mut in b cells
failure of pre b lympho dev in bone marrow
so low circulating mature b lymphos
low igMGAE
maternal passive imm wanes 3-6 mos
recurrent severe / chronic sinopulmonary otitis media pna gi salmonella campylo infections
pe older kids underdev tonsils lns lymphoid tissue… but not normally very prominent anyway
ivig and ppx abx

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33
Q

presentation of cvid vs xla

A

common variable immunodef same but less severe sx after adolescence w dec serum ig’s but norm b cell count

x linked (bruton) agammaglobulinemia severe recurrent sinopulm or gi infections in late infancy, low/absent ig’s AND b cells

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34
Q

22q11.2 deletion syndrome aka

A

digeorge syndrome

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35
Q

digeorge syndrome aka

A

22q11.1 deletion syndrome

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36
Q

classic triad digeorge

A

congenital heart defect
t cell deficiency
hypocalcemia

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37
Q

xla vs 22q11.2 keys

A

xlinkedbrutonagammaglob recur sinopilmonary gi inf late infancy no B cells no igs

digeorge recurrent bact fung inf no T cells

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38
Q

scid
presentation
labs

A

scid recurrant bact fung viral inf in infant, from t cell developmental impairment not stimulating b cells so low T AND B

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39
Q

transient hypogammoglobulinemia of infancy
pres
pathogenesis

A 
milder recurrent sinopulm and gi inf in infancy
dec igg
variable igm
normal igA and b cells
normalizes typically 9-15mos old
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40
Q

sudden onset hypotention tachycardia and back pain hours post cardiac cath suggests

A

retroperitoneal hematoma due to bleeding from arterial access site

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41
Q

most common complications of cardiac cath

A

local at catheter insertion site:

bleeding, hematoma local or with retroperitoneal extension, arterial dissection, thrombosis, pseudoaneurysm, av fistula

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42
Q

most hemorrhage or hematoma formation occurs within __ hours of catheterization

A

within 12 hours

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43
Q

quad screen
trisomy 18
trisomy 21
neural tube or ab wall defect

A

18 - everything down

21 - BhCG and Inibin A up, MSAFP and Estriol down

NTD AWD - MSAFP up

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44
Q

quad screen is done when

A

2nd trimester 15-20 weeks

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45
Q

next step after failure of nsaids / ocps for endometriosis

A

laparoscopy

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46
Q

typical ultrasound finding of dermoid cyst / cystic teratoma

A

hyperechoic nodules and calcifications

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47
Q

adnexal mass due to ovarian stimulation by high B-hCG levels (e.g. molar pregnancy) that resolves after levels decline. Do not present outside pregnancy. On ultrasound, multiseptated bilateral cystic masses, No calcifications or hyperechoic nodules

A

Theca Lutein cyst

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48
Q

young female with known dermoid cyst presents down the line with unilateral lower quadrant abdominal pain – tenderness to deep palpation and voluntary guarding… suspect __ not ___

A

Torsion - higher risk from mass

not rupture – that would have peritoneal signs, INvoluntary guarding… and much more common with Simple Ovarian and Corpus Luteum cysts… dermoid cysts Don’t typically rupture

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49
Q

Pelvic Pain in a patient with a Known Ovarian Mass should be suspected for ____ until proven otherwise

A

pelvic pain with known ovarian mass should be suspected for OVARIAN TORSION until proven otherwise

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50
Q

woman trying to conceive and attentive to… stuff… otherwise healthy notices 2 days clear vaginal discharge like uncooked egg white – it is…

A

peri-ovulatory cervical mucus - increases close to ovulation for sperm facilitation, thickens afterward… some women notice as “vaginal discharge”

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51
Q

what does a passed cervical mucus plug look like and what was its function in pregnancy

A

brown red or yellowish thick mucus
typically shed before or during labor
barrier to ascending infection during pregnancy

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52
Q

icu pt on pressors with symmetric duskiness and coolness of all fingertips - explain, and what else at risk

A

ischemia from pressor (such as norepi) - induced vasospasm in already hypotensive pt

at risk for mesenteric ischemia and renal ischemia as well

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53
Q

what is SVC syndrome

A

Compression of SVC by e.g. lung cancer, thrombi, or fibrosing mediastinitis causing Upper Extremity Edema

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54
Q

fetal Position vs Presentation

A

Position - relationship of presenting part to maternal pelvis

Presentation - lowest/presenting part of fetus

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55
Q

arrest of 2nd stage of labor due to transverse lie of fetal head in pelvis… call this malposition or malpresentation?

A

MalPosition - relationship of presenting part to maternal pelvis

(malpresentation refers to lowest/presenting part of fetus, e.g. vertex, face, breech)

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56
Q

vertex, breech, face

refer to position or presentation?

A

presentation (lowest/presenting part of fetus)

position is relationship of lowest part to pelvis

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57
Q

optimal fetal position

what is risk of alternate positions with same presentation

A

occiput anterior (occipital bone forward toward pubis, face back toward coccyx – facilitates cardinal movements of labor

cephalopelvic disproportion and arrest of labor a risk with occiput transversus or occiuput posterior

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58
Q

occiput anterior, posterior, transversus

refer to position or presentation?

A

Position - relationship of presenting part to maternal pelvis

(presentation is lowest/presenting part of fetus)

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59
Q

most common cause of arrest of 1st stage of labor and 2nd stage of labor

A

1st stage arrest - insufficient contractions

2nd stage arrest – cephalopelvic disproportion

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60
Q

ominous possible explanation for decreased fetal movement despite normal fetal heart tone

benign explanation

A

central nervous system hypoxia

fetal sleep cycle

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61
Q

contraindications to contraction stress test

A

contraindications to labor

placenta previa, prior myomectomy, etc

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62
Q

normal Amnionic Fluid Volume on biophysical prophile

A

single pocket ^2x1cm

AFI ^5
amnionic fluid index

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63
Q

normal fetal Movements, Tone, and Breathing Movements on biophysical profile

A

3 or more general body movements

^1 flexion/extension of fetal limbs or spine

^1 breathing episode for ^30sec

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64
Q

a score of 0-4/10 on BPP biophysical profile suggests

you should

A

Fetal Hypoxia due to Placental Dysfunction
aka Placental Insufficiency

Deliver promptly to avoid fetal demise

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65
Q

when to stop pap testing

A 
age 65 or hysterectomy
AND
no hx CIN2 or higher or immunocompromise or maybe smoking
3 consecutive negative Paps
OR
2 consecutive negative co-tests
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66
Q

TF

in patient with vulvovaginal atrophy and urinary incontinence the cause of both is estrogen deficiency

A

T

urinary incontinence because urethra has estrogen receptors and atrophies as well, losing tone

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67
Q

mechanism of urinary incontinence in vulvovaginal atrophy

A

estrogen deficiency

-urethral mucosa atrophies and loses tone

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68
Q

TF
postmenopausal woman with vulvogavinal atrophy and urinary incontinence… incontinence likely due to urethral hypermobility

A

F
estrogen deficiency
-urethral mucosa atrophies and loses tone without estrogen input

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69
Q

inheritance pattern of HOCM

mutated proteins

A

Autosomal Dominant

myocardial sarcomere contraction protein mutations

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70
Q

EKG changes in HOCM

A

LVH - tall R wave aVL, deep S wave V3

Repol changes in anterolateral leads I aVL V456

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71
Q

diagnostic test for pancreatic cancer according to jaundiced or not

A

jaundiced - Ultrasound - likely pancreatic head mass

not jaundiced - CT - body or tail tumor

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72
Q

when to start fertility investigation in couple trying to conceive

A

1 y mom v35yo

6 mo mom ^35yo

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73
Q

kussmaul sign

A

lack of decrease (or increase) in JVP during inspiration

74
Q

ekg in PE

A

sinus tachy

or nonspecific ST changes or T wave changes, new RBBB, S1Q3T3 pattern (acute cor pulmonale)

75
Q

ekg changes with fluconazole and moxifloxacin

A

QT prolongation

risk of Torsades

76
Q

treat Torsades in hemodynamically stable vs unstable pt

A

unstable - immediate Defibrillation

stable - Magnesium IV

77
Q

treat paroxysmal supraventricular tachycardia

A

Adenosine

78
Q

use of Atropine for ekg abnorm

A

Atropine for Symptomatic Sinus Brady or AV Block

79
Q

ekg changes with hyperkalemia

A

peaked T waves
P-R elongation
eventual widening of QRS
eventualll Sine Wave

80
Q

woman with epigastric pain and right shoulder pain for 4 hours after eating a cheeseburger = classic….

A

biliary colic

81
Q

“hollow organ contraction and outlet obstruction” in setting of epigastric pain and shoulder pain for 4 hours in a women after eating a cheeseburger refers to

A

biliary colic

82
Q

TF

pain from fat necrosis from acute pancreatitis can resolve spontaneously after a few hours

A

F

not usually spontaneously resolving in a few hours…. think more biliary colic

83
Q

biliary colic caused by contraction against obstructed cystic duct usually lasts less than __ hours

A

biliary colic lasts less than 6 hour usually

84
Q

a PE might seem like a MI of what ventricle at first presentation

A

may seem like Right Ventricle MI

(PE causes backup into RV and RV dysfunction)… but more dyspnea and syncope with PE and more arrhythmia and bradycardia with RVMI

85
Q

postmenopauseal bleeding, breast tenderness, and 10cm adnexal mass and thickened endometrial stripe on ultrasound – next step CT or endometrial biopsy?

A

endometrial biopsy

estrogen secreting Granulosa Cell Tumor high risk for causing Endometrial Carcinoma… must rule out

CT to stage after that

86
Q

cardioselective beta blockers (B1)

A

A-M

87
Q

TF

metroprolol is a cardioselective beta blocker (B1)

A

T

A-M are cardioselective

88
Q

FEV1
FEV1/FVC
FVC

obstructive vs restrictive lung disease (including obesity)

A

Obstructive
FEV1 v70%
FEV1/FVC v70%
FVC normal to decreased

Restrictive
FEV1 v80%
–Fev1/FVC ^70%
FVC v80%

89
Q

TF
55yo with new asthma symptoms and asthma PFTs on metoprolol probably caused by metoprolol rather than adult-onset asthma

A

F
metoprolol is A-M cardioselective (B1)
rarely causes asthma symptoms

Adult Onset Asthma is a thing not that uncommon even though asthma typically diagnosed younger

90
Q

worsening cough and wheezing in old guy preceded by refractory chronic rhinosinusitis with nasal polyposis could be due to what drug

A

aspirin

aspirin-exacerbated respiratory disease

91
Q

2 key PFT findings diagnostic of asthma regardless of age

A

^12% increase FEV1 reversible obstruction with beta agonist

with normal diffusion capacity for carbon monoxide

92
Q

elderly pt with “abdominal pain” limited to severe pain with brushing skin in a local area with negative TTP etc in setting of recent cancer treatment “chemo” likely attributable to ___

treat with ___ to accomplish ___

A

shingles, herpes zoster

even without rash, as pain may precede rash. often arises with severe physical stress (cancer treatment) or immunocompromise

treat with acyclovir valacyclovir or famciclovir to shorten duration and decrease risk of post-herpetic neuralgia

93
Q

adult respiratory distress symptoms presents very similarly to ___ but lacking the history and risk factors that would make you think ___

A

similar to CHF

without hx and risk factors

94
Q

renal effects of CHF

A

RAAS activation in response to decreased cardiac output, to increase contractility, peripheral vasoconstriction, and extracellular fluid volume

specifically
— ATII constricts EFFERENT glomerular arteriol more than afferent arteriol, and stims SODIUM resorption in CORTICAL COLLECTING TUBULE and adrenal ALDOSTERONE secretion

95
Q

pellagra is due to ___ and characterized by…

seen in populations…

A

pellagra is due to NIACIN deficiency (niacin from diet or synthesized endogenously from Tryptophan)

characterized by 3 Ds

  • Dermatitis - sun-exposed, rough, scaly, hyperpigmented
  • Diarrhea
  • Dementia - neuronal degeneration… memory, affective symptoms, psychosis
CORN diets (tryptophan unabsorbable)
MALNUTRITION (alcoholism, illness)
CARCINOID syndrome (depletion of tryptophan)
HARTNUP disease (congenital tryptophan malabsorption)
ISONIAZID therapy (eg TB) can interfere with tryptophan metabolism
96
Q

___ causes episodic not chronic abdominal pain, vomiting, diarrhea, often with neurologic agitation, paresthesias, confusion, may be triggered by isoniazid, with chronic transaminase elevation, more common in women than men

A

AIP

acute intermittent porphyria

97
Q

_____ is characterized by erythematous scaly plaques affecting scalp face chest intertriginous areas, can be associated with dementia/Parkinsons, does not typically affect the hands does not typically cause GI symptoms

A

seborrheic dermatitis

98
Q

skin findings with UC

A

erythema nodosum and pyoderma gangrenosum

99
Q

presentation classic for aortic dissection – diagnostic steps?

A

CT angio preferred if hemodynamically stable and normal creatinine

TEE (transesophageal echocardiogram) if Cr elevated Renal Insufficiency or hemodynamically Unstable

MR angio not preferred - contrast required and time-consuming in possibly emergent setting (type A aortic dissections are emergencies with mortality rates 1-2%/hour following onset

100
Q

probable aortic dissection with Cr 2
why Cr elevated?
diagnostic test?

A

dissection may extend to renal arteries
(or CKD)

TEE transesophageal echocardiogram for dissection with renal disease (no contrast)…. otherwise CT angio

101
Q

50yo heavy alcohol user, smoker, with compensated CHF, no cad, MCV ^100, thrombocytopenia, AST:ALT^2:1

diagnosis

best treatment for heart
-ACEI/ARB? Smoking cessation? Alcohol cessation? Salt restriction?

A

Alcoholic (dilated) Cardiomyopathy

STOP ALCOHOL improves or normalizes LV function over time

smoking contributes to CAD not CHF

Salt restritction, ACEI/ARB, BB, diuretics, possible aldosterone antagonists, digoxin etc all part of treatment per CHF but Alcohol Abstinence best for Alcoholic Dilated Cardiomiopathy

102
Q

time to ARDS onset after clinical insult

A

v1wk

103
Q

vent settings to treat ARDS

A

low TV, high PEEP, high FiO2

104
Q

hypoxia with PaO2/FiO2 v300 suggests

how to calculat PaO2/FiO2

A

suggests ARDS

e.g. 60mmhg/1.0 = 60
1.0 = 100% FiO2
90mmhg/.1 = 900
90mmhg/.2 = 450
90mmhg/.3 = 300

105
Q

TF

massive transfusion can cause ARDS

A

T

106
Q

Pleural fluid analysis in Uncomplicated vs Complicated Parapneumonic effusion

sterile or bacteria?
free or loculated?
pH, glucose, WBC, protein
gram stain culture
treatment
A

Uncomplicated - sterile, free-flowing, pH^7.2, glucose^60, WBCv50, low protein, negative cultures, antibiotics

Complicated - bacterial invastion, loculated vs empyema, pHv7.2, glucosev60, WBC^50, high protein, negative cultures still (bacterial load there but low), antibiotics and drainage

107
Q

difference between complicated parapneumonic effusion and empyema?

A

negative cultures vs gross pus or bacteria on gram stain

108
Q

parapneumonic effusion with continued fever and pleuritic pain despite abx suggests…

A 
Complicated parapneumonic effusion (persistent bacterial invasion but low enough for negative cultures)
or Empyema (gross pus / positive cultures)

requiring Drainage in addition to abx

109
Q

quantify “low protein” in a transudative effusion

A

v3g/dl

consider that normal serum total protein is 8

110
Q

the most frequent underlying arrhythmia responsible for sudden cardiac arrest in setting of acute MI

pathophys

A

Ventricular Fibrillation

Reentrant ventricular arrhythmia (predominant, If within 10 minutes of MI, from distorted conduction patterns)

abnormal automaticity if 10-60min post mi, less common

111
Q

pt with variceal bleed with hematemesis hemodynamically unstable with altered mental status - being transfused… next step NG tube to decrease hematemesis?

A

INTUBATE - protect airway (AMS, hematemesis, aspiration risk, cannot protect airway)

once protected, can move on to NG suction to improve EGD visualization, EGD for sclerotherapy/banding… also do octreotide (SS analogue) to decrease GI blood flow in meantime

112
Q

calculate cardiac index

A

cardiac output / body surface area

CO / BSA

113
Q

underlying cause of ascending vs descending aortic aneurysms

A

ascending - cystic medial necrosis (elderly) connective tissue disorders (marfan, ehlers danlos)

descending - ATHEROSCLEROSIS htn hld smoking

114
Q

TF

done diagnosing aortic aneurysm with a cxr?

A

F

could just be tortuous aorta… CT to confirm

115
Q

pt with fever, chills, malaise, headache, myalgias, dry cough

mediastinal or hilar lymphadenopathy with focal reticulonodular or miliary infiltrates on cxr

granulomas with narrow-based budding yeasts on biopsy

dx and risk factor?
treatment?

A

Histoplasma Capsulatum

Bird/Bat droppings - CAVES, Ohio/Mississippi river valleys, Northeast

complete spontaneous resolution in weeks
Itraconazole or Amphotericin B if not

116
Q

chest pain, cough, fatigue, fever

normal cxr or unilateral infiltrate with ipsilateral hilar LAD

spherules with endospores on biopsy

dx? risk?

A

Cocccidioidomycosis

Arizona

117
Q

Mononucleosis-like lymphadenopathy, fevers, malaise in cat owner think…

A

toxoplasma gondii

118
Q

fit preggy gymnast wants exercise advice

A

continue jogging, swimming, walking, stop gymnastics (as long as pregnancy uncomplicated by multiple gestation, placental concerns, heart or lung disease, prematurity concerns…)

(avoid contact sports, FALL RISK, scuba diving, hot yoga)

119
Q

physical activity to avoid in healthy pregnancy

A

contact sports
fall risk
scuba diving
hot yoga

120
Q

TF

bilateral wheezing can occur in acute PE

A

T

bronchoconstriction in response to hypoxia and infarction

121
Q

most common cause of mitral regurge, e.g. in otherwise healthy middle-aged person in a developed country

A

Mitral Valve Prolapse
(Myxomatous Degeneration)
MVP most common cause of MR
in developed countries

122
Q

pathophys of Mitral Valve Prolapse

A

myxomatous degeneration

123
Q

why avoid spillage of mature cystic teratoma / dermoid cyst contents during laparascopic cystectomy

A

can cause chemical peritonitis

124
Q

most common risk factors for aortic dissection

A

htn #1

marfan
cocain

125
Q

pathogenesis of exercise-induced bronchoconstriction (athletic asthma)

treatment

A

mast cell degranulation triggered by passage of high volumes of dry cold air

SABA before exercise if a few times per week

can substitute ICS or AntiLeukotriene if exercise daily

126
Q

most common cause of adult-onset diarrhea due to malabsorption presenting between age 20-40

A

lactose intolerance

127
Q

30yo with chronic crampy abdominal pain bloating and watery diarrhea after meals likely has ___

A 
Lactose Intolerance
(brush border enzyme deficiency)
128
Q

normal function and location of intestinal lactase

A

process lactose into glucose and galactos on the Brush Border of the Duodenum

129
Q

quality of diarrhea in Lactose Intolerance, why

mechanism of bloating

A

watery diarhea
-undigested lactose draws water into intestinal lumen and decreases transit time

colonic bacteria ferment lactose producing hydrogen gas

130
Q

diagnose lactose intolerance

treat

A

diagnosed by resolution of symptoms with lactose-free diet
or lactose breath hydrogen test if above inconclusive

treat by avoiding lactose or supplementing lactase

131
Q

acute onset watery diarrhea and low-grade fever and positive FOBT with PPI therapy think…

A

C Diff

  • associated with PPI use
  • FOBT often positive
  • diarrhea is ACUTE with Low Grade FEVER
132
Q

quality of diarrhea in Celiac

A

foul-smelling, greasy

133
Q

escalating symptoms of magnesium toxicity

treatment

A

nausea flushing headache hyporreflexia
areflexia, hypocalcemia, somnolence
respiratory paralysis, cardiac arrest

stop mag
give IV calcium gluconate bolus

134
Q

2 uses of mag sulfate in OB

A

prevention of eclamptic seizures

preterm delivery – decreases risk of cerebral palsy in premies

135
Q

magnesium excretion

how does that inform your OB practice

A

renal

so watch out if renal failure or increased Cr, check levels and signs of toxicity always

136
Q

how does mag therapy cause hypocalcemia

A

mag temporarily suppresses PTH secretion

137
Q

TF

LEEP and Cervical Laser Ablation increase risk of preterm delivery

A

Fish

knife conization definitely

LEEP maybe

Laser definitely not

138
Q

this trumps all other risks for preterm delivery

A

history of preterm delivery

trumps multiple gestation, short cervicle lenth, cervical conization surgery, cigarette use, obesity, etc

139
Q

OB risks associated with gastric bypass surgery

risk for preterm delivery?

A

anemia in pregnancy
cesarean delivery

Not a risk for preterm delivery

140
Q

manage history of preterm delivery in currently pregnant mama

A

cervical length measurements by TVUS
progesterone administration
maybe cerclage placement if diagnosie cervical insufficiency

141
Q

hypotensive chest trauma patient has normal/high PCWP that elevates with fluid bolus, don’t think hemorrhage now think…
get…

A

think myocardial dysfunction, possible contusion

get an urgent echocardiogram

142
Q

most common infective endocarditis organism

A

staph aureus

143
Q

valve involvement in infective endocarditis

A

tricuspid more than aortic

144
Q

fever cough chest pain in IV drug user with systolic murmur that increases with inspiration and scattered round lesions in the peripheral lung fields bilaterally think..

A

infective endocarditis with tricuspid involvement and septic emboli to lungs

145
Q

describe paradoxical split S2

and 3 examples that cause it

A

reversed, A2 follows P2, with split increased during Expiration and decreased with inspiration

seen with Fixed Left Ventricular Outflow Obstruction
-Aortic Stenosis
-LBBB
Right Ventricular Paced Rhythm

146
Q

TF

inadequate pregnancy weight gain, e.g. from hyperemesis gravidarum, can cause fetal growth restriction

A

T

147
Q

congenital malformation caused by lymphatic system obstruction in the fetal neck

aka
association

A

aka Cystic Hygroma

assoc with Aneuploidy eg Turner Syndrome

148
Q

RhD antii-D immunoglobulin is given in OB Only After…

A

only after delivery of baby an blood type checked (Rh pos baby to Rh neg mom), within 72 hours of delivery

149
Q

can get a FAST for an altert and hemodynamically stable trauma pt…. what SBP indicates hemodynamically stablility?

A

SBP^90

is a sign of hemodynamic stability

150
Q

woman with HTN COPD and OSA has swollen legs and varicose veins with medial ankle ulcer…

diagnosis
recommend treatment
if fail treatment

A

chronic venous insufficiency
(nothing to do with COPD OSA or HTN… risk factors are age, obesity, family history, pregnancy, sedentery, prior trauma)

elevate legs and compression stockings

if fail this, get venous duplex ultrasound to demonstrate venous reflux and confirm diagnosis

151
Q

TF

diuretics for chronic venous insufficiency

A

F
will just dehydrate

-elevate legs and compression stockings

152
Q

TF

smoking cessation for chronic venous insufficiency

A

F
no evidence that stopping helps, though it is known to be a risk factor

-elevate legs and compression stockings

153
Q

symptoms on presentation of choriocarcinoma

first lab test

treatment

A

amenorrhea or abnormal uterine bleeding
pelvic pain / pressure uterine mass
mets to lung / vagina and assoc sx

elevated b-hCG is first lab

chemo is treatment

154
Q

within 6 months of pregnancy, delivery, abortion, molar pregnancy, woman has episodes of vaginal bleeding, large uterus, and lung symptoms

suspect
get
treat

A

suspect choriocarcinoma (with mets to lungs)

get b-hCG

treat with chemo

155
Q

most common site of choriocarcinoma mets

A

choriocarcinoma mets to lungs

156
Q

when to deliver baby in preeclampsia with severe features vs without severe features

A

^34 wks severe features

^37 wks no severe features

mag and antihypertensives (Hydralazine, Labetalol, Nifedipine) till then

157
Q

TF

alpha methyldopa to for blood pressure control in preeclampsia

A

F
alpha methyldopa for Chronic htn in pregnancy

conrtol Htn in Preeclampsia with IV HYDRALAZINE, IV LABETALOL, or PO NIFEDIPINE

158
Q

how to choose antihypertensive med for preeclamptic preggy

A

avoid Labetalol if already bradycardic

avoid Nifedipine (PO) if emesis suggests po intolerance

Hydralazine IV… pretty ok…

159
Q

why are ACEIs contraindicated in pregnancy

A

can cause

fetal growth restriction
renal failure
pulmonary hypoplasia
oligohydraminos
skeletal abnormalities
160
Q

why is sodium nitroprusside generally a Last Resort for treatment of hypertension

A

Cyanide is a metabolic byproduct

161
Q

predominant Mechanism responsible for rapid anginal pain relief from Nitrates like Nitroglycerin

A

decreased left ventricular Wall Stress
via venodilation, decreased preload, decreased end diastolic volume resulting in decreased myocardial oxygen demand…

*wall stress more so than decreased contractility from decreased preload, or coronary dilation

162
Q

pt with amenorrhea and history of chemo… otherwise ROS pretty negative,

suspect
FSH LH PRL TSH levels?

A

suspect Ovarian Failure from Chemotherapy (targets rapidly dividing cells)

FSH LH up (lack of inhibition from estrogen)
PRL TSH normal

163
Q

abdominal succussion splash

describe
diagnosis
further diagnostic workup

A

stethoscope over upper abdomen
rock patient at hips

GOO - retained gastric material ^3 hours after a meal will generate a splash sound in a hollow viscus filled with fluid and gas (most sensitive for GOO, but must follow up with workup below)

NGT suctioning, IVMF, Endoscopy to confirm dx

164
Q

explain the muscle weakness side effect of albuterol, eg with newbs in treatment of asthma exacerbation

what else can result of this mechanism

first step if occurring

A

Beta2Agonists like Albuterol can drive K into cells, HypoKalemia, Muscle Weakness, Arrhythmias, EKG changes… also Tremor, Palpitations, Headache

first step BMP to assess K level

165
Q

treat hypertriglyceridemia

150-500
vs
^1000

and what is initial goal of therapy when triglycerides ^1000

A

150-500 - lifestyle Weight Loss, Alcohol decrease, Exercise increase, High Dose Statin IF CAD or High Risk

^1000 (initial goal Prevent Pancreatitis)
-Fibrates, Fish Oil, Abstain from Alcohol

166
Q

triglycerides 465 in CAD patient – what to do other than start high dose statin?

A

150-500 - lifestyle Weight Loss, Alcohol decrease, Exercise increase, High Dose Statin IF CAD or High Risk

^1000 (initial goal Prevent Pancreatitis)
-Fibrates, Fish Oil, Abstain from Alcohol

167
Q

most effective pharmacologic therapy for lowering triglyceride levels

when to use it

A

Fibrates most effective for lowering triglycerides

use for SEVERE Hypertriglyceridemia ^1000 – otherwise risky for myopathy and statins more effective by evidence so statins first-line for most CAD and moderate triglyceridemia

168
Q

75yo DM and HTN, with cupping of optic disk on exam, loss of peripheral / tunneling of vision, why?

treat

A

OPEN Angle Glaucoma - cupping of optic disk

BB (Timolol) eye drops initial mgmt
Laser Trabeculoplasty as adjunct
Trabeculotomy if refractory

169
Q

presentation of open vs closed angle glaucoma

A

Open - gradual loss of peripheral vision / tunneling, cupping of optic disk

Closed - Sudden onset Blurred Vision, Severe eye Pain, Nausea, Vomiting, Red eye with Hazy Cornea and Fixed Dilated Pupil

170
Q

20yo with atypical chest pain and short systolic murmur at the apex that shortens with squatting… diagnosis?

A

MVP mirtal valve prolapse

squat, increase venous return… larger LV volume, delayed prolapse? per UWorld… thinking…. better stretched… less distance to prolapse….

MVP gets SOFTER with squat
MR gets LOUDER with squat

171
Q

which gets louder with squatting and which gets softer MR vs MVP

A

MR gets LOUDER with squat
(more LV volume to regurge)

MVP gets SOFTER with squat
(more LV stretch, tighter chordae… less distance to flick back)

172
Q

1st and 2nd most common Murmurs caused by Rheumatic Heart Disease

A

RHD
MS Mitral Stenosis #1
MR Mitral Regurge way less often

173
Q

3 things to do in order for eeclampsia

A

give mag

give anihtn (hydralazine labetalol nifedipine

deliver baby

174
Q

4 risk settings for ARDS

vent settings to treat with

how to avoid mortality

A

infection
trauma
massive transfusion
acute pancreatitis

treat with Mechanical Ventilation
-LOW TV, high PEEP, Permissive HyperCapnia

AVOID alveolar OVERDISTENSION (barotrauma) (low TV)
GOAL SpO2 ^88%

175
Q

Pt put on vent for ARDS

what is the MOST important treatment strategy to avoid mortality?

A

Avoid Alveolar OverDistension (barotrauma) (low TV)

GOAL SpO2 ^88%

176
Q

most common causes of Malignant pleural effusions

A

lung carcinoma
breast carcinoma
lymphoma

177
Q

top 4 ddx for hypokalemia with alkalosis and normotension

how does urine chloride help you differentiate

A

surreptitious vomiting - low urine chloride

diuretic abuse
Bartter syndrome (renal protein mutation)
Gitelman’s syndrome (renal protein mutation)
(all high urine chloride)

178
Q

what kind of acid/base disturbance in chronic diarreha

A

metabolic ACIDOSIS

from loss of bicarb in stool

179
Q

How can COPD exacerbation lead to seizure

and how can over-supplementation of oxygen contribute? Guidelines for use?

A

Seizure by HYPERCAPNIA (causes brain metabolite signaling changes) and reflex cerebral VasoDILATION

use Oxygen Cautiously with Goal SpO2 90-93% or PaO2 60-70mmHg
Too Much can Worsen HyperCapnia by:

  • Loss of Hypoxic pulmonary Vasoconstriction and worsening V/Q mismatch.. increased deadspace perfusion
  • Decreased CO2 reuptake because more O2 saturation
  • Suppressed Hypoxic Respiratory Drive
180
Q

Goal SpO2 and PaO2 in oxygen supplementation for COPD exacerbation

A

In COPD exacerbation, use Oxygen Cautiously

with Goal SpO2 90-93% or PaO2 60-70mmHg
Too Much can Worsen HyperCapnia by:

  • Loss of Hypoxic pulmonary Vasoconstriction and worsening V/Q mismatch.. increased deadspace perfusion
  • Decreased CO2 reuptake because more O2 saturation
  • Suppressed Hypoxic Respiratory Drive
181
Q

how can Zollinger-Ellison syndrome cause impaired fat absorption?

A

Gastrin producin tumor
high Acid
Impaired Pancreatic Enzyme Activation by duodenal base and Injury to the Mucosal Brush Border

182
Q

workup of Zollinger-Ellison Syndrome

A

Gastrin level ^1000
Gastric pH v4

Endoscopy for ulcers (duodenal and maybe jejunal)

CT MRI SomatoStatin Receptor Scintigraphy to ID Pancreatic tumors (tumor often located in pancreas) and Mets

once confirmed, screen for MEN1 with PTH, Ca, PRL levels

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